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IV Hydration Therapy Consent 

Please fill out the following form to consent for minor as parent or legal guardian:

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I have informed the nurse and/or physician of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or physician of my medical history.

Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure or prevent any medical disease. These IV infusions are not a substitute for your physician’s medical care.

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.

I understand that:

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

  1. Alternatives to IV therapy are oral supplementation and dietary and lifestyle changes

  2. Risks of IV therapy include but are not limited to

    1. Occasionally: discomfort, bruising and pain at the site of injection

    2. Rarely: inflammation of the vein used for injection, phlebitis, metabolic disturbances and injury

    3. Extremely rarely: severe allergic reaction, anaphylaxis, infection, cardiac arrest and death

    4. Benefits of IV therapy include:

      1. a) Injectables are not affected by the stomach or intestinal absorption problems

      2. b) Total amount of infusion is available to the tissues

      3. c) Nutrients are forced into cells by means of high concentration gradient

      4. d) Higher doses of nutrients can be given than possible by mouth without intestinal irritation

I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or physician(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or physician(s) to exercise judgement during the course of treatment with regards 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.

Thanks for submitting!

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