Form

Vitamin Injection Consent

    Patient Information








    Liability Waiver

    1. 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.

      1. 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.

      2. Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.

      3. Risks of intravenous therapy include:

        1. Discomfort, bruising and pain at the site of injection.

        2. Inflammation of the vein used for injection, phlebitis.

      4. Benefits of intravenous therapy include:

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

        2. Total amount of infusion is available to the tissues.

        3. Nutrients are forced into cells by means of a high concentration gradient.

        4. Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

    2. 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.

    3. 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.







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