consent form

Your Name *

First

Last

Date of Birth *

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Phone *

Email *

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Emergency Contact

Name *

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Last

Cell Phone *

Relationship to the client *

I have informed the provider at Skinfinity Therapeutics of any known allergies to medications or other substances as well as known medical history. *

• YES
• NO

I understand that intravenous (IV) infusion therapy and any claims made about the infusion 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 and that IV therapy is not a substitute for a physician's medical care. *

• YES
• NO

I understand that I have the right to be informed of therapy, alternatives to therapy, and possible risks and benefits involved; therapy will not be administered until informed consent is obtained. *

• YES
• NO

I understand the procedure involves inserting a needle into my vein and injecting, by gravity, the prescribed IV solution; I understand that alternatives to IV therapy are oral supplements and/or lifestyle changes. *

• YES
• NO

I understand the possible risks of IV therapy include but are not limited to: Occasionally-discomfort, bruising, or pain at the IV site; Rare-inflammation of the vein used for injection, phlebitis, metabolic disturbances, or injury; Extremely rare-Severe allergic reaction, anaphylaxis, infection, cardiac arrest, or death. *

• YES
• NO

I understand the benefits of IV therapy include: Injectables are not affected by the stomach or intestinal absorption difficulties making the total amount of the infusion bioavailable. Nutrients are forced into the cells by means of a high concentration gradient, higher doses can be given by IV than by mouth without stomach/intestinal irritation. *

• YES
• NO

I am aware that there are unforeseen complications of therapy that can occur. I do not expect the nurse to anticipate or explain all the risks and complications. I rely on Skinfinity Therapeutic providers to exercise judgement during my treatment with regards to the procedure. I have had the opportunity to have all my questions answered. *

• YES
• NO

I understand I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form means that I have given my consent to IV infusion therapy. *

• YES
• NO

I acknowledge and give consent to be photographed or videotaped for promotional or educational purposes. *

• YES
• NO

My checkmark below confirms that: 1). I understand the information provided on this form and agree with the above statements, 2). IV therapy has been adequately explained to me by the Skinfinity Therapeutics provider, 3). I have received all the information and explanation I require concerning the procedure, 4). I authorize and consent to the performance of IV therapy, 5). I hereby release Luis Enrique Liogier-Weyback, MD, Heather Mouser-Fields, RN, Skinfinity Therapeutics LLC, and all medical staff from liability for any complications or damages associated with IV Therapy. *

• YES, I understand.

By typing my name, I am signing this release form. *

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