CONSENT FORM

Infored Consent for Treatment. I consent to all nutrient Injections rendered by the doctor(s), medical assistants or nurses employed by or associated with Modern Wellness Concierge

I understand that there are risks to vitamin nutrient Injections Including but not limited to pain, bruising, inflammation, injury, infection,

allergic reactions, headaches, dry mouth, dificulty sleeping, diarthea, blurred vision, unpleasant taste, increased urination, cramps, and metabolic disturbances. I do not expect the persons employed or associated with Modern Wellness Concierge to anticipate and or explain all risk and possible complications.

I hereby release the doctors at Modern Wellness Concierge from all liabilities regarding my treatment with vitamin/nutrient Injections. I understand that nutrient Injections may not be approved by the United States Food and Drug Administration for the treatment of my medical condition.

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.