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Informed Consent 

This document is intended to serve as confirmation of informed consent for IV therapy as ordered by the provider at Replenish IV Hydration and Wellness LLC

I have accurately documented any known allergies to drugs or other substances, or of any past reactions to anesthetics.

I have accurately documented all current medications and supplements.

I, understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits.

Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

Side Effects/Risks 

 I understand that:

1. The procedure involves inserting a needle into a vein and injecting the prescribed solution or injecting a solution into a muscle.
2. Alternatives to intravenous/injectable therapy are oral supplementation and / or dietary and lifestyle changes.
3. Risks of intravenous/Injectable therapy are included but not limited to:
     a. Occasionally to commonly:
            i. Discomfort, bruising and pain at the site of injection.
           ii. General feeling of warmth during and after injection
     b. Rarely:
            i. Inflammation of the vein used for injections, phlebitis, metabolic disturbances, and injury
           ii. Reactive Hypotension (or rapid drop in blood pressure)
          iii. Reactive Hypoglycemia (or rapid drop in blood sugar)
     c. Extremely Rarely: Severe allergic reaction, anaphylaxis infection, cardiac arrest and death.

Benefits of intravenous/injectable therapy include:

1. Injectables are not affected by stomach or intestinal absorption problems.
2. The total amount of infusion is available to the tissues.
3. Nutrients are forced into cells by means of a high concentration gradient.
4. Higher doses of nutrients can be given than possible by the mouth without intestinal irritation 

The Procedure

The IV intravenous procedure involves inserting a needle into your vein and infusing IV fluids over a determined period of time or prescribed nutrients (vitamins, minerals, amino acids). Your vitals will be measured prior to and after your infusion.

The injectable procedure involves injecting a small amount of solution into a muscle with a needle. The needle is inserted to inject the vitamins and then removed. 

What Safety Precautions Must You Take?

  • Monitor the insertion site for signs and symptoms of infection (redness, swelling, discharge). Notify the clinic immediately. If your experience a sustained fever greater than 101, do not delay treatment and go to the ER as this can be a sign of sepsis.
  • If you experience any side effects the infusion will be stop. It will be determined if you can restart at a lower rate or if your infusion needs to be discontinued. For sever symptoms staff will make a call to 911. 

My Consent for Nutrient Infusion Therapy is Voluntary 

My request for nutrient infusion therapy as described is entirely voluntary and I have not been offered any inducement to consent. I understand that I may refuse treatment at any time.

Statement of Person Giving Informed Consent

I have read this consent form and understand the information contained in it. I understand the risks and benefits and have had the opportunity to have all my questions answered to my satisfaction. I am aware that others that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and or explain all the risk and possible complications that could arise. I rely on the provider(s) to exercise judgment during the course of my treatment with regard to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I give my consent to IV nutrient therapy/ IM therapy.

RELEASE OF MEDICAL INFORMATION

I hereby authorize Replenish to disclose my medical records, to EMS, my spouse, and emergency contact. I also authorize Replenish to discuss my care and share my medical information with my primary care physician for the purpose of monitoring, quality control or safety concerns.

Today's date: April 22, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Last Name*

Phone*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*

Phone*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*

Phone*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*

Phone*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*

Phone*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*

Phone*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*

Phone*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*

Phone*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*

Phone*
Tenth Client's Date of Birth*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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