Introduction
This form provides information about intravenous (IV) vitamin and wellness therapy. Please read carefully before signing. Ask any questions you may have.
Purpose of IV Therapy
IV therapy may include fluids, electrolytes, vitamins, minerals, amino acids, or other nutrients. These infusions are intended to support hydration, energy, immunity, recovery, and overall wellness. They are not intended to diagnose, treat, or cure any medical condition.
Potential Benefits
- Rapid hydration and replenishment
- May improve energy and focus
- May support immune function
- May reduce fatigue and aid recovery
- May promote skin, hair, and nail health
- May assist with travel recovery or hangover relief
Possible Risks & Side Effects
As with any IV infusion, risks exist, including but not limited to:
- Pain, redness, or bruising at the IV site
- Temporary swelling or irritation at the infusion site
- Risk of infection at the IV site (rare)
- Infiltration or vein irritation (phlebitis)
- Allergic reaction (rash, itching, or difficulty breathing; rare but possible)
- Dizziness, lightheadedness, or fainting
- Electrolyte imbalance (very rare)
Contraindications
IV therapy may not be appropriate if you:
- Are pregnant or breastfeeding (unless cleared by your physician)
- Have kidney, liver, or heart disease
- Have uncontrolled high blood pressure
- Have known allergies to any infusion ingredients
Please disclose your full medical history to your provider.
Payment & Insurance
I understand that IV therapy is an elective service. It is not covered by insurance and payment is due at the time of service.
Patient Acknowledgment
- I have disclosed my complete medical history, medications, and allergies.
- I understand the purpose, benefits, and potential risks of IV therapy.
- I understand this therapy is elective, and results may vary.
- I release My IV Therapy Club and its providers from liability related to adverse effects.
- I understand I may refuse treatment at any time.