IV Infusion and Injection Consent Form

This form outlines that you understand that a peripheral intravenous catheter will be inserted into a vein in your body, and you will have fluids, vitamins, minerals, nutrient, and/or medications infused directly into your body. This is considered “IV Infusion Therapy.” If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.”

After reading each point, please initial acknowledging that:

I have informed (H2O2U IV Hydration Services LLC )of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all of my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.*

I understand that IV infusion and injection therapy will not prevent, treat, or cure and medical condition or disease. Furthermore, I understand that I am here seeking IV infusion and/or injection therapy voluntarily to assist with certain symptoms or ailments I may be experience.*

I understand that serious adverse events could happen if I do not disclose all of my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.*

I understand that IV therapy has not been evaluated by the US Food and Drug Administration (FDA) and is not intended to diagnose, treat, cure, or prevent any medical disease. *

I understand that the procedure involves inserting a needle into a vein or having a solution injected into my muscle or body fat.*

I understand that common risks involved with IV and injection therapies include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the IV insertion or injection.*

I understand that rare side risks involved with IV and injection therapies include, but are not not limited to, infection at the site of the IV insertion or injection, injury to the tissue, phlebitis, low blood pressure, fainting, fluid volume overload, medication interactions, and drops in blood sugar levels. Rare risk may also include but are not limited to sepsis, severe allergic reactions, severe medication/supplement interactions, anaphylaxis, blood clots, shock, cardiac arrest, and death*

I understand that the benefits of IV and injection therapies include, but are not limited to, enhanced absorption of vitamins and minerals as they bypass the digestive tract and increased total body hydration. These therapies may also increase total body nutrient density and improved performance/recovery.*

I affirm that I am voluntarily seeking IV infusion and injection therapies at H2O2U Mobile IV Hydration Service, LLC and have not been coerced into doing so*

I understand the risks and benefits of the procedure, IV infusion therapy, and injection therapy and have had all my questions answered to my full satisfaction.*

I understand that unforeseeable complications can arise when an IV is placed and medications/fluids/minerals/vitamins are infused into the body.*

I understand that I have the right refuse any treatments or treatment recommendations at H2O2U IV Hydration Services LLC*

Treatment with IV and injectable vitamins/hydration/nutritional/mineral and/or medications offered at H2O2U Mobile IV Hydration Service, LLC is completely voluntary in nature. Alternative therapy for the symptoms you are seeking IV infusion and injectable therapy for include, not are not limited to, ongoing treatment by your primary care provider and/or specialty provider, oral supplementation, and dietary/lifestyle modifications.

I acknowledge that IV infusion and injection therapy provided at H2O2U Mobile IV Hydration Service, LLC is voluntary in nature and that I am seeking out this therapy on my own or from the recommendation of my referring provider. I acknowledge that I have also notified my medical and/or mental health provider about my decision to undergo IV and injectable vitamin/hydration/nutritional/mineral therapy. I acknowledge the alternative treatment options and have voluntarily decided to pursue IV and injectable therapy.

Name*

First NameLast Name

Signature*

Date*

Date

H202U Mobile IV Hydration Services (240-814-4718)

IV Infusion and Injection Consent Form

Voluntary Nature of Treatment and Alternative Therapies