1. I (the above-noted) am over the age of 18 years
or older and am of sound legal mind to authorize and consent to the use of IV hydration therapy.
2. I have read the information sheet and hereby authorize my medical provider and/or such assistants as may be selected by my medical provider to perform the IV hydration therapy.
3. I understand what my medical provider can and cannot do, and understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All of my questions have been answered.
4. I understand the specific risks to the procedures I seek, as well as those additional risks and complications, benefits, and alternatives. Understanding all of this, I elect to proceed.
5. I understand that multiple treatments may be necessary to achieve desired results.
6. I understand that clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment.
7. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and /or court cost and reasonable legal fees, should this be required. No refunds will be given for treatments received. I understand that if complications arise, I will be responsible for the cost of any treatment.
8. I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures.
9. For purposes of advancing medical education, or staff training, I consent to the admittance of observers to the treatment room.
10. I have informed the clinical staff of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics. I have noted all of these on the patient history form.
11. I have informed the clinical staff of any history or current/recent use of recreational/illicit drugs, understanding this could affect my outcome or reactions.
12. I have informed the clinical staff of all current medications and supplements and documented on the patient history form.
13. I have informed the clinical staff of my prior medical history and documented in the patient history form.
14. To my knowledge, I am not pregnant and I am not breast feeding. I understand it is not recommended to receive IV hydration therapy in pregnancy or with breast feeding.
15. I understand that I may suspend or terminate my treatment at any time by informing my medical provider.
16. I understand that I am experiencing any adverse effects or symptoms after I receive IV hydration therapy, I will seek medical evaluation.
17. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated.
18. I understand that I can withdraw my consent at any time.
