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Informed Consent for IV and Injection Therapy

By signing this form you are giving Dr. Meredith Bull permission to perform intravenous (IV) and intramuscular (IM) nutritional therapy and confirming your understanding of the risks and benefits of these procedures.
Name *

First Name Last Name
I. Benefit and Use

These procedures are recommended for replacement of
- essential nutrients,
- correction of deficiencies, and
- for other therapeutic effects such as improving immune function, improving antioxidant status, reducing oxidative damage, improving fatigue, etc.
This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed.

II. Risks of intravenous therapy include but are not limited to:
- Discomfort, bruising or pain at the injection site
- Skin rash
- Nausea, dizziness, fatigue, feeling light-headed
- Flushing
- Headache
- Lowering of blood sugar levels
- Lowering of blood pressure
- Thrombophlebitis (inflammation of the veins, often due to irritation)
- Life-threatening anaphylactic reactions including cardiac arrest
III. Medical Screening
I will inform Dr. Bull of any diagnoses of uncontrolled hypertension, uncontrolled diabetes, heart disease, kidney disease, or liver disorder. *

I agree
To the best of your knowledge, have you ever experienced any of the following: *

Anaphlyaxis (severe allergic reaction - hives, swelling of the mouth, tongue, lips, eyes, trouble breathing, etc.) Unexplained fainting Seizures IF NONE CHECK HERE
If yes to any of the above or you have any additional health information to disclose, please provide a brief explanation or speak to Dr. Bull before treatment is administered.
I understand the above and authorize administration of intravenous or intramuscular vitamins, minerals, and other nutrients. *

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Informed Consent for IV and Injection Therapy