Consent Form

I,
Name(Required)

hereby give consent to Living Water Hydration and Health (LLHH) to perform intravenous and intramuscular vitamin and mineral therapy.  I understand that receiving intravenous nutrient therapy can carry risks (although rare).  I have truthfully answered all questions regarding my medical history and have informed the staff about all prescription and/or over the counter medications (including oral vitamins) as well as recreational drugs.  I understand that after consultation and review of my medical history that I could be advised not to receive IV fluids and could be denied services.   I acknowledge that the sole risk of injury or harm resulting in any manner from my voluntary participation in LLHH services rests entirely with me to the extent that I fail to disclose my health conditions, medications, or drug usage in advance to the services provided.  Furthermore, I am responsible for any medical care I may have that is directly or indirectly related to the services provided by LLHH.  If I seek medical treatment for any side effects or reaction, it will be at my own expense.

You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits.  The procedure involves inserting a needle into your vein or muscle and injecting a formula that specifically meets your health and wellness needs.  The alternatives to intravenous/intramuscular therapy are oral supplementation and/or dietary and lifestyle changes.

The risks of intravenous / intramuscular therapy include:

  • discomfort, bruising and pain at the site of injection
  • inflammation of the vein used for injection, phlebitis
  • malaise or fatigue post infusion
  • reactive hypoglycemia (drop in blood sugar)
  • allergic reaction, anaphylaxis, and/or death

The benefits of intravenous / intramuscular therapy include:

  • IV Hydration is 100% effectively absorbed into your bloodstream so your body can deliver the fluids to the cells and tissues that need it the most. The body converts the nutrients more beneficially than oral intake.  Oral intake is absorbed less than 50%.  IV hydration is a faster, more efficient way to hydrate your body.
  • Intravenous/Intramuscular injections are easier on your digestive system.
  • Reduced recovery time. The mixture of vitamins, nutrients, and fluids allows you to get back to feeling great in less time.
  • It supports and boosts your immune system
  • It flushes toxins from your system
  • It can be customized to your body’s needs

I understand that the following will reduce the efficacy of intravenous (IV) and intramuscular (IM) therapy and that it may take more treatments to reach optimal health.  Cigarette smoking, drug usage, certain medications, caffeine consumption, and poor diet.

You have the right to consent to or refuse the proposed treatment any time prior to its performance.  Your signature on this form affirms that you have given your consent for the procedure.  The procedure will be performed under the direction of the medical director and certified health care professionals at LLHH.

I have read the above and give my consent:

I am 18 years old or older, of sound mind, and given my consent for IV/IM hydration and nutritional procedures.

I have received information regarding Living Water Hydration and Health services

The procedure set forth has been adequately explained by the attending health care professional

This document serves as an informed consent for Living Water Hydration and Health Services

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