I, understand that I have the right to be informed of the procedure, any feasible alternative options, and the benefits and risks. Except in emergencies, procedure is not performed until I have had an opportunity to receive such information and to give my informed consent.
The procedure involves inserting needle into the vein or muscle and injecting the medical solutions described by the treatment provider.
Alternatives to IV therapy can be IM injections, oral supplementations 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 I have right to refuse of proposed treatment at any time prior to its performance. If the procedure has not been performed by any reason refunds are provided according to the Refund Policy of the Mobile IV company.
I understand that procedure is performed by the qualified nurse under directive of a physician. I understand all the information about the intravenous infusion procedure which has been adequately explained to me. I understand this elective procedure and I hereby voluntarily consent to treatment and agree to forego. I hereby indemnify the service provider of this treatment from any liability relating to the procedures that I have volunteered for.
I certify that I have read the content of Infusion Solution and I don’t have known allergy to its ingredients, I don’t have known bleeding disorders. I am not pregnant (for women).
My signature affirms that I have given my informed consent to the procedure with any different or further procedures which, in the opinion of treatment provider, may be indicated. I also state that I understand English.
