You 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 you have had the opportunity to receive such information and to give your informed consent.

a. The procedure involves inserting a needle into your vein or muscle and injecting a formula/protocol recommended by your doctor.
b. Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.
c. Risks of intravenous therapy include, but are not limited to:

○ Discomfort, bruising and pain at the site of injection
○ Inflammation of the vein used for injection, phlebitis.
○ Severe allergic reaction, anaphylaxis, cardiac arrest and death.

d. Benefits of intravenous therapy include:

○ Injectables are not affected by stomach or intestinal disease.
○ 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.

e. You have the right to consent to or refuse any proposed treatment at any time prior to its performance. Your signature in this form affirms that you have given your consent of the procedures which, in the opinion of your doctor may be indicated.

● You understand the information provided on this form and agree to the foregoing.
● The procedures set forth above have been adequately explained to you by your doctor.
● You have received all the information and explanations you desire concerning the procedure.
● You authorize and consent to the performance of the procedures.