Intravenous (IV) Infusion and Injection Therapy Consent Form
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I have informed Hydration Plus of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed Hydration Plus of my medical history. I understand that any claims made about these IV infusions or injections have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions and injections are not a substitute for your physician’s medical care. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. I understand that the following will reduce the efficacy of IV infusion and injection therapy and that it may take more treatments to reach optimal health: Cigarette smoking/vaping Caffeine consumption (increases vitamin C excretion) Poor diet: processed foods, high sugar intake, nutrient deficient diets Heavy metal toxicity I understand that: The procedure involves inserting a needle into a vein (IV therapy) or intramuscularly (injection therapy) and injecting the prescribed solution. Risks of intravenous or injection therapy include, but are not limited to: Occasionally: Discomfort and bruising at the site of injection, redness, swelling Rarely: Inflammation of the vein used for IV therapy, infiltration at IV insertion site, metabolic disturbances, and injury. Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death. Benefits of intravenous and injection therapy include: Injectables are not affected by stomach or intestinal absorption problems. Total amount of infusion is available to the tissues for use. Nutrients are forced into cells by means of a high concentration gradient. Higher doses of nutrients can be given than possible by mouth without intestinal irritation. I am aware that other unforeseeable complications could occur. I do not expect the staff of Hydration Plus to anticipate and or explain all risks and possible complications. I rely on the staff of Hydration Plus to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that having IV infusion or injection therapy can cause symptoms such as fever, fatigue, headaches, or nausea, which may be signs of my body detoxifying. My signature below confirms that: I understand the information provided on this form and agree to all the statements made above. Intravenous (IV) infusion therapy has been adequately explained to me by the staff of Hydration Plus. I have received all the information and explanation that I desire concerning the procedure. I authorize and consent to the performance of intravenous (IV) infusion therapy. I release the healthcare practitioner, Hydration Plus LLC, and all the staff from all liabilities for any complications or damages associated with my intravenous (IV) infusion therapy. I acknowledge that I am responsible for the payment of any services I receive. To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity, or cause of my health concern. I grant permission to Hydration Plus to utilize photographs and videos, in any of the following: Social media Print advertisements Company I hereby affirm that such release to Hydration Plus does not constitute any form of compensation, including royalties arising from the photographs or videos, to my benefit. I understand and agree that photographs and videos in the possession of Hydration Plus shall become the property of Hydration Plus. The use and publication of the photographs however, shall conform to my rights as a subject of said photographs. I agree that my typed name below will be recognized as my electronic signature.
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