Vitamin IV Infusion Consent

1

Patient Information* This field is required.

First Name

Last Name

Date of Birth

2

ProcedureThis is authorization for the performance of the following procedure(s):

Ultrasound

Pellet Insertion

IUD Removal and/or Insertion

Sonohysterogram

Vulvar Biopsy

Endometrial Biopsy

Vitamin IV Infusion

3

Provider* This field is required.This procedure is to be performed under the direction of:

Julie Morin, WHNP-BC

4

Vitamin IV Infusion SelectionThe therapy I have chosen today includes:

Myers' Cocktail (Vitamins B1, B2, B3, B5, B6, and B12, magnesium chloride, and Vitamin C)

Glutathione (an anti-oxidant)

Calcium Carbonate

5

About Vitamin IV Infusions* This field is required.Please review all terms before selecting the box.

6

Terms of Release* This field is required.Please review all terms before selecting the box.

7

Authorized Person* This field is required.Please select the person signing this authorization.

Patient

Parent

Legal Guardian

Other

8

Authorized Person Information

First Name

Last Name

Date of Birth

9

Authorized Person Signature* This field is required.