I understand this treatment is an elective medical-cosmetic treatment and hereby acknowledge the following:

I am voluntarily consenting to having I.V. Therapy.

_____I understand that participating in the intravenous (I.V.) hydration and vitamin administration services carries risks.

_____I understand that failing to inform the staff about my medical issues and/or drug use can lead to serious complications.

_____I understand that I am undertaking this treatment knowing the full facts, side effects, treatment outcomes and complications and I will not hold the clinic responsible should any issues mentioned above occur.

_____I acknowledge that I am responsible for any medical care I may have that is directly or indirectly related to the services provided .If I seek medical treatment for any side effect or reaction, it will be at my own expense.

_____I understand that the clinic or therapist bears no responsibility for and will not screen for, diagnose, monitor, or provide any care for such conditions. I acknowledge that the clinic relies upon information provided by me in assessing my ability to participate in the services provided.

_____ 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:
   • Occasionally to commonly: Discomfort, bruising and pain at the site of injection.
   • Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
   • Extremely Rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.
4. Benefits of intravenous therapy include:
   • Injectables are not affected by stomach, or intestinal absorption problems.
   • Total amount of infusion is available to the tissues.
   • Nutrients are forced into cells by means of a high concentration gradient.
   • Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

______I acknowledge that I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications, and consequences associated with the procedures.

______I am aware that it is impossible to foresee or predict all possible risks, complications, and consequences, and I do not expect that staff can anticipate or explain all associated risks. I waive any and all claims related to the services provided and agree to hold the clinic and practitioner harmless regarding any complications or consequences I experience during or following the service.

_____Under GDPR rule I understand that I have full access to all data held on me. This data will be held by the clinic for no longer than 6 years for insurance purposes, after which, digital information will be deleted permanently, and paper documents will be destroyed. All information on myself is kept on password encrypted hard drives or locked in filing cabinets to which only selective staff members have access. None of my personal data will be sold or used for anything other than to provide the services of this clinic.