Please Complete Your Consent Form

I hereby request and voluntarily consent to treatment with IV therapies of vitamins, and micronutrients and placement of an IV catheter by THE DRIPBaR. I can request explanation of the procedure or methods of treatment, and information about the material risk of the procedure or treatment. I understand as with drugs, nutritional supplements and IV therapy nutrients may cause some side effects in certain sensitive individuals, may interact with certain medications or lab tests, or exhibit symptoms due to certain preexisting disease conditions. I wish to rely on the medical professional engaged by THE DRIPBaR to exercise judgment in recommending the IV nutrients that she feels at the time, based on the facts then known, is in my best interest. I have had the opportunity to ask questions and discuss the following with THE DRIPBaR to my satisfaction:

• My suspected diagnosis or condition;

• The nature, purpose and potential benefit of the proposed care;

• The inherited risks, complications, potential hazards, or side effects of the proposed treatment/procedure;

• Reasonable available alternatives to the proposed treatment/procedure; and

• The possible consequence if the treatment advice is not followed.

I have informed the nurse and/or provider of any known allergies to medications or other substances and of all current medications and supplements. I have fully disclosed my entire medical history including any prescription drugs and other supplements that I'm currently using. I understand that I should share with my other treating physicians the nature of my therapy. I have no kidney, liver, heart or other medical conditions to disclose that could be a barrier to receiving the IV infusion or IM shot.

IV therapy/IM therapy and any claims made about these services have not been evaluated by the

U.S. Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These infusions and IM shots are not a substitute for my physician's medical care.

I understand that I 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 I have had an opportunity to receive such information and to give my informed consent.

I understand that in the practice of IV therapy there are some risks of examination and treatment and that the following possible complications could occur, although they are very unlikely:

Bruising at the site where the needle is inserted. If this occurs, it should resolve in one to two days.

Slight bleeding when the needle is removed, but it is easily controlled with a little pressure using a clean cotton ball.

There is a low risk of potential infection. Infection can occur at the site of the needle, however, pre-sterilized disposable needle and intravenous supplies are used to avoid such risk.

Allergic reaction to a nutrient, a needle, or other supplies used is a potential risk. However hypoallergenic supplies are used to reduce this risk. In the event of an allergic reaction, therapeutic interventions will immediately follow to stop such a reaction. This is why it is important to inform THE DRIPBaR of any possible allergies you may have before your treatment begins,

There is a potential to feel warming or burning sensation at the site of the needle or in the vein that therapy is being administered through. Please inform THE DRIPBaR immediately if this occurs. This may be a normal feeling for certain treatment solutions. However, if you are in discomfort or distress, tell THE DRIPBaR immediately.

There is a potential for dizziness, feeling faint, or changes in blood pressure and blood sugar during or following your treatment due to some nutrients. Inform THE DRIPBaR immediately if you feel any of these symptoms. Your safety is a priority and every effort will be made to insure your safety.

Other rare. but possible side effects include: lever.

I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or

provider(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s)

and/or provider(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees, should this be required.

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby knowingly and voluntarily, for myself and for my heirs, executors, representatives, agents, administrators, successors, and assigns, hereby irrevocably and unconditionally release THE DRIPBaR, its affiliates, directors, officers, employees, contractors, representatives and agents from any and all actions, causes of action, suits, debts, charges, complaints, liabilities, obligations, promises, agreements, controversies, damages, liens, liquidated damages, losses, liabilities, settlement payments, penalties, assessments, citations, directives, claims, litigation, demands, defenses, judgments, proceedings, costs, disbursements, and expenses of any kind or of any nature whatsoever related to the intravenous/subcutaneous mistletoe therapy. I hereby give consent to perform this and all subsequent IV/IM therapies with the above understood.

I have read and understand the above. Under the conditions indicated, I hereby place myself under the care of The DripBar for IV / IM nutrient therapy, and agree to the above release: 

• I understand the information provided on this form and agree to the all statements made above.

• IV and IM Infusion Therapy has been adequately explained to me by my nurse and/or provider.

• I have received all the information and explanation I desire concerning the procedure.

• I authorize and consent to the performance of IV/IM Infusion Therapy.

• I release THE DRIPBaR, and all the medical staff from all liabilities for any complications or damages associated with my IV/IM Therapy.