IV Consent Form "*" indicates required fields First Name*Last Name*Email Address* Phone Number*Date of Birth Month Day Year Consent Agreement* I agree to the following termsI hereby authorize the following procedure: administration of intramuscular vitamins, minerals, and other nutrients. This procedure is recommended for the replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, decreasing bronchospasm, improving fatigue, etc. The principal side effects that may accompany intramuscular administration of nutrients include: - Burning or soreness at the site of surrounding tissue. - Muscular spasms, weakness, or fatigue. - Allergic reactions (rare). - Local thrombophlebitis (very rare). This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been recommended. This therapy is recommended with the belief that it is of potential benefit and can improve the condition for which you are under treatment and in your overall health. I understand that I may suspend or terminate my treatment at any time by informing my medical provider. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for a redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I hereby place myself under your care for intramuscular vitamin therapy and agree to the above release. I verify that all information presented to the medical provider in my medical history is true to the best of my knowledge. I verify I do not have a suppressed immune system due to any chronic medical conditions or medications. I verify I do not have impaired renal function, cardiovascular disease, or G6PD deficiency I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment for these conditions.PhoneThis field is for validation purposes and should be left unchanged.