This document is intended to serve as confirmation of informed consent for IV Vitamin Therapy as ordered by the provider at Salus Wellness.

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1. I have informed the practitioner of any known allergies to drugs or other substances, or of any past reactions to anesthetics.

2. I have informed the practitioner of all current medications and supplements.

3. 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.

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Side Effects/Risks

I understand that the risks of IV Vitamin Therapy include but are not limited to:

• Occasionally / commonly:

  • Discomfort, bruising and pain at the site of injection

  • General feeling of warmth during and after injection

• Rarely:

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

  • Reactive hypoglycemia (or rapid drop in blood sugar)

  • Reactive hypotension (or rapid drop in blood pressure)

• Extremely Rare:

  • Severe allergic reaction, anaphylaxis, infection, cardiac arrest or death

Benefits of IV Vitamin Therapy Include

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

2. 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 mouth without intestinal irritation

The Procedure

The IV Vitamin Therapy procedure involves inserting a needle into your vein and infusing fluids over a determined period of time and/or prescribed nutrients (vitamins, minerals, amino acids).  Your vitals will be measured prior to and, at times, after your infusion. Alternatives to IV Vitamin Therapy are oral supplementation and / or dietary and lifestyle changes.

Safety Precautions

• Monitor the insertion site for signs and symptoms of infection (redness, swelling, discharge).  Notify the clinic immediately if you notice any of these symptoms.  If you 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 a minor side effect while you are at home, you should contact Salus Wellness, otherwise contact your medical provider or call 911.

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My Consent for IV Vitamin Therapy is Voluntary

My request for IV vitamin therapy as described is entirely voluntary and I have not been offered any inducement to consent.  I understand that I may refuse treatments 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 other unforeseeable complications could occur.  I do not expect the provider(s) to anticipate and or explain all risk and possible complications.  I rely on the provider(s) to exercise judgment 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 of 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 vitamin therapy.