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Vitamin injection and/or IV Vitamin Infusion Informed Consent

Before Receiving a Vitamin Injectable Treatment: 

Avoid medications that inhibit clotting such as vitamin E, aspirin, or non-steroidal anti-inflammatory drugs for seven days prior to treatment.


During a Vitamin Injectable Treatment:

You will feel a small needle injection and a slight stinging sensation, which will last about 3-5 seconds.

After Vitamin Injectable Treatment:

·      Ice may be used for any discomfort but usually none is required.

·      Bruising/swelling at injection site may occur.

Possible side effects of Vitamin Injectable Treatment:

Although generally safe when administered properly, these injections may cause side effects or adverse reactions, including but not limited to:

  • Pain, redness, bruising, or swelling at the injection site
  • Nausea, dizziness, or headache
  • Mild allergic reaction (rash, itching)
  • Serious allergic reaction (anaphylaxis), although rare
  • Interference with lab tests (particularly with high-dose Biotin)
  • Risk of kidney stones with high doses of Vitamin C
  • Bronchospasm in asthma patients (with Glutathione)
  • Tingling or numbness (with high-dose B6)
  • Vision loss in patients with Leber’s disease (with B12)

These injections are not recommended for individuals with:

  • Known hypersensitivity to any ingredient
  • G6PD deficiency (Vitamin C)
  • Active asthma (Glutathione)
  • Leber’s optic atrophy (B12)
  • Significant kidney or liver impairment
  • Pregnancy or breastfeeding, unless cleared by a physician 

Please read and initial next to each statement:


I acknowledge that I have disclosed any medical conditions, allergies, or medications to my provider.


I understand the nature and purpose of the treatment, including its potential benefits and risks.


I understand that results vary and that this is not a substitute for medical treatment or diagnosis of any underlying condition.


I understand that while vitamin injections are generally safe, there is no guarantee of results or outcomes.


I agree to contact my provider if I experience any adverse reactions or unexpected symptoms.


I voluntarily consent to receive one or more of the listed vitamin injections and authorize the staff at Lüz Lounge to perform the procedure.


CONSENT: By signing below I acknowledge that I have read the foregoing; informed consent and agreed to the treatment. I hereby give consent to perform this and all subsequent Vitamin injections with the above understood.

I hereby request and authorize Lüz Lounge to perform the following procedure – Vitamin Injections. It has been explained to me the potential risks involved. I agree to fulfill the aftercare instructions noted above to help reduce these possible effects and optimize the effectiveness of the treatment.

I am aware the use of Vitamin Injections for energy or weight loss is considered “off label” and is not approved by the FDA. I therefore authorize Lüz Lounge personnel to perform the requested procedures. I understand the pre and post-treatment protocol and accept the risks to undergo this procedure. Any questions I may have been answered satisfactorily.

My signature certifies, I do understand the goals, limitations, alternative treatments, and possible complications of Vitamin Injections.I voluntarily wish to proceed with the procedure. The procedure has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily.

I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and understand the above medical questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.

STATE  MEDICAL SERVICES CONTRACT  All Medical treatments are performed by medical staff members of the Luz Lounge. A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement CD0501Y8v2 ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by State law, and not by a lawsuit or resort to court process except as State law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforce ability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph.  Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court or a federal district court. Discovery shall proceed in accordance with State Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division.  Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. 

I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this agreement upon request.


 May 23, 2025




First Client's Name
First Name*
Last Name*
First Client's Age Acknowledgment*
First Client's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Second Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Third Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fourth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fifth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Sixth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Seventh Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Eighth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Ninth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Tenth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes
Any allergies to medications or food?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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