IV Consent

First Name

Middle Name

Last Name

Birthdate

Email

Any Allergies?

Past Medical History

Treatment Requested:

Radiant Recharge LLC provides facilities and personnel to assist your Provider in the performance of intravenous therapy. 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 an opportunity to receive such information and to give your informed consent.

The procedure involves inserting a catheter, guided by a needle into your vein or muscle and injecting the formula described above by your physician or Nurse Practitioner.
Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.
Risks 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.

You have the right to consent to or refuse and postponed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent to the procedure(s) described above.
The procedure will be performed by or under the direction of the physician or Nurse Practitioner named above with qualified medical personnel.
Your signature below means that:
You understand the information provided on this form and agree to the foregoing.

The procedure(s) set forth above has been adequately explained to you by your physician or Nurse.
You have received all the information and explanation you desire concerning the procedure.
You authorize and consent to the performance of the procedure(s).

I acknowledge that I have received a copy of Radiant Recharge LLC's HIPAA Privacy Notice.

If signed by representative, indicate relationship: