CONSENT FORM

IV TREATMENTS

IV Treatments

We are providing you with IV injection vitamin boosts. Vitamins and Minerals are essential for the cells to function at the optimal level. Intravenous infusions are the fastest, most effective way for your body to receive hydration and micronutrients, allowing your bloodstream to serve as the route for your cells to uptake what your body needs right away.


This document is intended to serve as confirmation of informed consent for IV therapy as ordered by the practitioner at Modern Wellness Concierge.

Patient Information

If you purchased a package: An injection will be deducted from your package for every missed appointment or late cancellation (less than 24 hours notice).

Patient Information

I understand that:

1. The procedure involves inserting a needle into a vein and injecting the prescribed solution.

2. Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.

3. Risks of intravenous therapy include but not limited to:

     a. Occasionally to commonly:

          i. Discomfort, bruising and pain at the site of injection.

     b. Rarely:

          i. Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

     c. Extremely Rare:

          i. Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.

     d. Benefits of intravenous therapy includes:

          i. IV parental infusion' are not affected by stomach or intestinal absorption problems.

          ii. Total amount of infusion is available to the tissues.

          iii. Nutrients are forced into cells by means of a high concentration gradient. 

          iV. Higher doses of nutrients can be given than is possible by oral consumption without intestinal irritation.

My signature on this form affirms that:

1. I have given my consent to receive IV therapy with any different or further procedures which, in the opinion of

my physician(s) or other associated with this practice, may be indicated

2. I have received all the information and explanation I desire concerning the procedure.

3. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its

performance.

4. I am aware of the risks mentioned above and I rely on the practitioner(s) and registered nurse to exercise

judgement during the course of the procedure with regards to my procedure

5. I understand that all nutrient infusions given at Modern Med Centers, are valued by their off-label use and

they are not approved by the Food Drug Administration (FDA) for the treatment of my, or any medical

condition.

6. I understand that the following will reduce the efficacy of IV nutrition therapy and that it may take more treatments to reach the optimal health:

     i. Certain medications

     ii. Caffeine consumption increases Vitamin C excretion

     iii. Poor diet, processed food, high sugar intake, nutrient-deficient diets.

     iv. Heavy metal toxicity.

IV

Treatments

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Vitamin

Shots

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Peptide

Therapy 

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Hormone

Replacement

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Regenerative PRP

& Stem Cells

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Medical Weight Loss

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