IV therapy Consent Form

I, ______________________________ , understand that

I have the right to be informed of the IV therapy procedure (or package of procedures), any feasible alternative options, and the benefits and risks. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed written or verbal consent.

The procedures involve inserting a needle into the vein and injecting the medical solutions described by the treatment provider.

Alternatives to IV therapy can be IM, SC injections, oral supplementation and/or dietary and lifestyle changes.

Benefits of IV therapy include but not limited by the fact that a total amount of infusion is available to the tissues as it is not affected by digestive system, nutrients are forced to the cells by means of a high concentration gradient, high doses of nutrients can be given than possible by mouth without intestinal irritation, the expected result can be obtained faster than the result with oral intake.

Risks of IV therapy include but not limited by discomfort, bruising, pain or necrosis at the site of injection, inflammation of the vein, used for injection, severe allergic reactions, anaphylaxis, cardiac arrest or death. I freely resume these risks of complications or injuries from both known and unknown causes. The risk of an unsatisfactory result is also possible and I understand that no guarantees are implied as to the outcome of the procedures.

I understand that the offered IV therapy is a supportive therapy that does not substitute conventional medical therapy for disease treatment.

I understand that I have the right to refuse proposed treatments at any time prior to their performance. If the procedures have not been performed by any reason refunds are provided according to the Refund Policy of the Mobile IV company.

I understand that procedures are performed by the qualified nurse under the directive of a physician. A physician’s consultation is obtained by request. I understand all the information about the intravenous infusions which has been adequately explained to me. I understand these elective procedures and I hereby voluntarily consent to treatments and agree to forego. I hereby indemnify the service provider of these treatments from any liability relating to the procedures that I have volunteered for.

I certify that I have read the content of Infusion Solutions and I do not have known allergy to its ingredients, I do not have known bleeding disorders. I am not pregnant (for women).

My signature affirms that I have given my informed consent to the procedures with any different or further procedures which, in the opinion of the treatment provider, may be indicated. I also state that I am over 18 years old and I understand English.

Date:                                                         Patient’s signature: