LIT Therapeutics/Clinic Consent Form

For IV Hydration, Intramuscular (IM) Injections, & Subcutaneous (SC) Injections
LIT CLINIC & LIT THERAPEUTICS MEDICAL CONSENT FORM
PATIENT INFORMATION
Full Legal Name*
Date of Birth MMDDYYYY*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
City
Address
Emergency Contact Name
State
ZIP
Emergency Contact Phone Number
Format: (000) 000-0000.
PERTINENT MEDICAL HISTORY List any relevant medical conditions diagnoses or concerns
CONSENT FOR IV HYDRATION, IM, & SC INJECTIONS
I voluntarily consent to receive IV hydration therapy, intramuscular (IM) injections, and/or subcutaneous (SC) injections at LIT Clinic & LIT Therapeutics. I understand that these procedures involve the administration of fluids, vitamins, medications, or other substances directly into my body.

1. PURPOSE & BENEFITS

IV Hydration Therapy is designed to replenish fluids, electrolytes, and essential nutrients. IM and SC Injections may be administered for therapeutic or wellness purposes, including but not limited to vitamin supplementation, medication administration, or other treatments deemed appropriate by the provider.
Initials*
2. POSSIBLE RISKS & SIDE EFFECTS

IV Hydration: Pain or bruising at the injection site, swelling, infection, vein inflammation, allergic reactions, or electrolyte imbalances. IM & SC Injections: Pain, redness, swelling, bruising, allergic reactions, or infection at the injection site. Rare but serious complications: Nerve damage, blood clots, or anaphylactic reactions.
Initials*
3. PATIENT RESPONSIBILITIES

I will inform the provider of all known allergies, medical conditions, and current medications. understand that results vary and no guarantees are made regarding treatment outcomes. I have had the opportunity to ask questions and all questions have been answered to my satisfaction.
Initials*
4. LONG-TERM CONSENT VALIDITY

This consent remains valid for a period of up to ten (10) years from the date signed, unless new pertinent medical information is provided, in which case a new consent form will be completed and signed.
Initials*
5. RELEASE & HOLD HARMLESS

I release LIT Clinic & LIT Therapeutics, its staff, and affiliates from any liability arising from treatment, except in cases of gross negligence or willful misconduct.
Initials*
Minors Name
Minors Date of Birth

MonthDayYear
Date
Parent/Guardian Name
Relationship to Minor
SIGNATURES
Patient Signature*

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Parent/Guardian Signature if applicable

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Date*

MonthDayYear
Date
Date

MonthDayYear
Date
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LIT CLINIC & LIT THERAPEUTICS MEDICAL CONSENT FORM

PATIENT INFORMATION

CONSENT FOR IV HYDRATION, IM, & SC INJECTIONS

SIGNATURES