The fine print.
Informed Consent For Intravenous (IV) Therapy
I hereby give my informed consent for the intravenous administration, vitamin therapy, vitals,
basic health risk assessments (prior to any service), and/or other related health services (not
including medicine or any medical treatment), (collectively referred to as “IV Therapy”) as set
I understand that this Document is intended to serve as confirmation of informed consent for IV
Therapy as ordered by a licensed physician and facilitated by RECHARGEIV INC.
______I acknowledge that I have completed the medical questionnaire and that all information
is/was answered truthfully, honestly, accurately, and to the best of my knowledge.
______I acknowledge that I am completing this Informed Consent truthfully, honestly,
accurately, and to the best of my knowledge.
______That I do not have a history of heart disease, diabetes, high blood pressure, swelling in
the ankles, stroke, carotid vascular disease, abdominal aortic aneurysm, am not currently
pregnant, and above the age of 18 years old
______Prior to the service, I have/will inform the technician of any and all known allergies to
the drugs or other substances that may be included in the ingredients of my solutions, or of any
past reactions to anesthetics.
______Prior to the service, I have/will inform the technician of all current medications and
supplements I am currently taking.
______I acknowledge that the technician is using all new and clean, including needles, etc., and
that I will watch the technician remove said items from their new and clean packaging.
______I acknowledge that I am not now impaired and/or under the influence of illegal drugs
_____ I acknowledge that during the procedure I will not be impaired by and/or be under the
influence of any alcohol and/or illegal drugs and will confirm same with the technician upon
______ I acknowledge that if the technician believes that I am impaired by and/or am under the
influence of alcohol and/or illegal drugs, that in technician’s sole discretion, the technician
may deny me the services, subject to the cancellation policy below.
_____ I acknowledge that I will be physically present at the location where the IV Therapy to
take place PRIOR to the technician’s arrival. I further acknowledge that if I am not physically
present at the location where the IV Therapy is to be provided upon the technician’s arrival, that
such services will be cancelled subject to the cancellation policy below.
____ That I have read and agree to the Cancellation Policy Below.
Medical information, personal information, and history divulged during my IV Therapy will be
kept strictly confidential unless I consent to sharing my information by way of a signed release.
I understand that I have the right to be informed during the procedure, and the risks and benefits.
except in emergencies. Procedures are not performed until I have had the opportunity to
receive such information and have given my informed consent by executing this document.
The IV Therapy intravenous procedure involves inserting a needle into your vein and infusing
over a determined period of time, prescribed nutrients (vitamin, minerals, and amino acids).
I understand that risks, benefits and alternatives to IV’s may include but are not limited to:
1) The Risks and potential side effects
a) Discomfort, bruising, and pain at the site of injection
b) Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
c) Severe reaction, anaphylaxis, cardiac arrest, or death.
2) The Benefits
a) Injectables are not affected by stomach or intestinal disease.
b) Total amount of infusions enters the bloodstream and is available to the tissues.
c) Intravenous hydration allows for an increased absorption of vitamins that cannot always
be achieved by oral supplementation. Intravenous therapy avoids the vitamin being
broken down in the stomach, which can help avoid irritation to the gastro intestinal tract.
3) Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and
I understand that IV Therapy is not a substitute for medicine, medical treatment, or the diagnosis,
treatment, or cause of disease by a medical provider.
I am aware that other unforeseeable complications could occur. I do not expect the technician(s)
to exercise judgement during the course of treatment with regards to my IV Therapy. I
understand the risks and benefits of the IV Therapy and will have the opportunity to have all my
I understand that I have the right to consent to or refuse any proposed treatment at any time prior
to its performance, subject to the cancellation policy below. With that said, By clicking “I
Accept” I affirm that I have given my consent for IV therapy with any different or further
procedures, which in the opinion of my physician(s) or other(s) associated with this
practice, may be indicated.
Cancellation Policy: If your appointment is not cancelled within five (5) minutes of ordering
services, you will be charged in accordance with the below:
• If you cancel after 5 minutes but prior to the technician’s arrival, you will be charged
a $10.00 service fee.
• If you cancel, refuse to consent, and/or refuse the services once the technician has
arrived or anytime thereafter, you will be charged a $35.00 service fee.
• If the technician arrives for your scheduled service and you are not physically present
at the location where the services are to take place, you will be charged a $35.00 service
• If the technician, in their sole discretion, believes that you are impaired by and/or are
under the influence of alcohol and/or illegal drugs, and the technician denies you
services, you will be charged a $35.00 service fee.
I agree to hold RECHARGEIV INC. harmless for claims or damages in connection with IV
Therapy, I understand that this is a release of potential liability.
I understand the information provided on this form and agree to the foregoing, I understand that
there is no implied or stated guarantee of success or effectiveness of any treatment. The
procedures set forth above have been adequately explained to me by the technician. I understand
that I am free to withdraw my consent and to discontinue participation in their treatment at any