Instructions:

• Adult Patients (18+): Please complete Sections I, II, and III. In Section V, select "Adult Patient (18+)" and complete the signature block.
• Parents/Guardians of Minor Patients: Please complete all sections (I, II, III, and IV). In Section V, select "Parent/Legal Guardian of Minor Patient" and complete the signature block.
• Legal Guardians of Adult Patients: Please complete all sections (I, II, III, and IV). In Section V, select "Legal Guardian of Adult Patient" and complete the signature block.

This document is intended to provide you with important information regarding Intravenous (IV) and Intramuscular (IM) Nutrient Therapy, including its potential risks, benefits, and alternatives, so you can make an informed decision about your treatment.

I. PROCEDURE AND PURPOSE

Nature of the Procedure: I hereby authorize the medical providers and staff of this practice to perform the following procedure: administration of intramuscular (IM) and/or intravenous (IV) vitamins, minerals, amino acids, and other nutrients.

Purpose and Potential Benefits: This procedure is recommended for the replacement of essential nutrients, correction of deficiencies, and for other therapeutic effects. Potential benefits may include, but are not limited to:

• Improving immune function
• Enhancing antioxidant status and reducing oxidative damage
• Improving energy and reducing fatigue
• Decreasing bronchospasm
• Improving overall health and well-being

II. RISKS, ALTERNATIVES, AND IMPORTANT ACKNOWLEDGMENTS

Potential Risks and Side Effects: I understand that while this procedure is generally safe, it is not without potential risks and side effects. The principal side effects that may accompany the administration of nutrients include:

• Discomfort, burning, stinging, bruising, or pain at the site of the injection or infusion.
• Inflammation or swelling of the vein (phlebitis or thrombophlebitis).
• Infiltration of fluid into the surrounding tissue if the IV catheter becomes dislodged.
• Muscular spasms, weakness, or fatigue.
• Allergic reactions, which can range from mild (rash, itching) to severe (anaphylaxis), though these are rare.

Reasonable Alternatives: I understand that alternatives to this procedure exist, which may include oral supplementation and dietary modifications. The risks and benefits of these alternatives have been explained to me, and I have had the opportunity to ask questions.

Acknowledgment of Elective and Potentially Unproven Status: I understand that this procedure may be considered medically unnecessary by some medical professionals and insurance carriers. It may or may not mitigate, alleviate, or cure the condition(s) for which it has been recommended. I understand this therapy may be considered "off-label" use by the FDA and may be considered unproven by scientific testing and peer-reviewed publications. This therapy has been recommended to me in the belief that it is of potential benefit, and I have elected to proceed based on my own judgment.

III. PATIENT'S CONSENT AND ACKNOWLEDGEMENTS

By checking the boxes and signing below, I confirm the following:

Please check each box to confirm your understanding and agreement:

IV. CONSENT ON BEHALF OF ANOTHER PATIENT (MINOR OR INCAPACITATED ADULT)

(This section must be completed by the parent or legal guardian)

By signing in the section below, I, the undersigned, affirm that I am the parent or court-appointed legal guardian of the patient named below. I have read and fully understand this consent form, including the risks and benefits of the proposed IV/IM nutrient therapy. I have been given the opportunity to ask questions, and they have been answered to my satisfaction. I hereby give my full consent and authorization for this practice to administer this therapy to the patient. I certify that I have the legal authority to act on behalf of the patient in making medical decisions.

A. Patient's Full Name:

B. Patient's Date of Birth: 

C. Relationship to Patient:

V. SIGNATURES

By signing below, I acknowledge that I have read, understood, and agree to all the terms outlined in this consent form. I understand that typing my name constitutes a legally binding electronic signature in accordance with the Florida Electronic Signature Act.

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