Day of Visit Consent Form

Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Any chance you are pregnant?*

YesNoUnknownN/A

I have had the nature of the procedure and/or treatment, the benefits of treatment, the risks of treatment, the side effects, the alternative therapies for my medical condition or symptoms I am seeking treatment for, and the chances of treatment success explained to me. I have had all my questions and concerns answered to my satisfaction. I acknowledge that I have been given sufficient information about IV hydration/vitamin/mineral/nutrient infusion and injection therapy and all its associated risks and benefits upon which to make an informed decision about treatment.
I acknowledge that there are no guarantees regarding the results of treatment and its effect on my presenting condition.
I give my consent for the use of emergency intervention if required during treatment.
I certify that I am of sound mind and body to make medical decisions and to consent for treatment.
I certify I will continue to remain under the care of a licensed and qualified primary care provider and/or mental health provider as IV infusion and injection therapy is considered an adjunctive and non-medically necessary treatment option, not a complete one.
I release ADVANCED BIOCARE and all the medical staff from all liabilities for any complications or damages associated with IV infusion and injection therapy.
I have read this consent and fully understand the information within it and I voluntarily authorize and consent to the treatment options, including but not limited to IV infusion therapy, provided to me at ADVANCED BIOCARE

I, First Name* Last Name* , agree
to indemnify, defend, protect, and hold harmless the medical providers employed
by ADVANCED BIOCARE; and their respective officers, directors, employees,
stockholders, assigns, successors, and affiliates (Indemnified Parties) from,
against, and in respect of all liabilities, losses, claims, damages, judgments,
settlement payments, deficiencies, penalties, fines, interest and costs,
expenses suffered, sustained, incurred or paid by the indemnified parties, in
connection with, results from or arising out of, directly or indirectly, the
medical providers employed ADVANCED BIOCARE; rendering medical care, services,
advice, and/or treatment, my failure to disclose all relevant information
regarding my medical and physical condition, acts or omissions, the medical
providers employed by ADVANCED BIOCARE: harm or injury resulting from medical
care or pharmaceuticals provided directly or indirectly by the medical
providers employed by ADVANCED BIOCARE. I am aware of the potential side
effects associated with IV infusion and injectable therapies provided by ADVANCED
BIOCARE, accept all the risks involved with IV infusion and injectable
therapies, and will not seek indemnification or damages from the indemnified
parties.

Printed Name*

Signature*

Date*

Date

Final Consent For Treatment

Indemnification Clause