,hereby authorize the following procedure: administration of intravenous vitamins, minerals, and other nutrients.
This procedure is recommended for replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, decreasing bronchospasm, improving fatigue, etc. I expressly represent and warrant to Alive Hydration & Wellness that I have never been diagnosed with, nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in regimens, programs or services made available by Alive Hydration & Wellness and I am choosing not to participate with any expectation that Alive Hydration & Wellness will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.
The procedure involves inserting a needle into your vein and injecting the medicine/additives prescribed by your provider (ie. Physician/NP/PA The principal side effects that may accompany intravenous administration of nutrients include: Theprincipal side effects that may accompany intravenous administration of nutrients include: -burning/stinging, bleeding, infection, swelling and/or scarring at the site of infusion or if IV infiltrates into surrounding tissue -muscular spasms, weakness, or fatigue, nerve injuries, fluid overload - light-headedness and/or fainting, allergic reactions (rare), - local thrombophlebitis, anaphylaxis, cardiac arrest and death (very rare)
This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health.
Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the health professionals at Alive Hydration & Wellness as is appropriate and necessary for my care.
I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure.