Infusion and Injection Informed Consent Form_SUMMIT

This form outlines that you understand that a peripheral intravenous catheter will be inserted into your vein, and you will have fluids, vitamins, minerals, nutrients, and/or medications infused directly into your body. This is considered “IV Infusion Therapy.” If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.”

_________ I understand that IV infusion and injection therapy at Discovery Well Being Infusion Lounge is not intended to diagnose or treat a specific medical condition.

_________ I understand that IV infusion and injection therapy will not prevent, treat, or cure a medical condition or disease. Furthermore, I understand that I am here seeking IV infusion and/or injection therapy voluntarily to assist with certain symptoms or ailments I may be experiencing.

_________ I have informed the staff at the Discovery Well Being Infusion Lounge of all the medications and supplements I am taking and declared any known allergies. I understand that serious adverse events could happen if I do not disclose all my medication/food/vitamin/ or other allergies and all the medications/supplements that I am currently taking.

_________ I understand that IV and injectable therapy and any claims made about these treatments have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. I understand that these treatments are not FDA approved for any given indication of treatment and are not considered a medical necessity.

_________ I understand that I have been informed of the procedure involving IV infusion and injections, and the risks and benefits of the mutually agreed upon treatment.

_________ I understand that the procedure involves inserting a needle into a vein or having a solution injected into my muscle or body fat.

_________ I understand that common risks involved with IV and injection therapies include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the IV insertion or injection.

_________ I understand that less common risks involved with IV and injection therapies include, but are not limited to, infection at the site of the IV insertion or injection, injury to the tissue, phlebitis, low blood pressure, fainting, fluid volume overload, medication interactions, and drops in blood sugar levels.

_________ I understand that rare side risks involved with IV and injection therapies include, but are not limited to, sepsis, severe allergic reactions, severe medication/supplement interactions, anaphylaxis, blood clots, shock, cardiac arrest, and death.

_________ I understand that the benefits of IV and injection therapies include, but are not limited to, enhanced absorption of vitamins and minerals as they bypass the digestive tract, increased total body hydration, alleviation of certain symptoms, increased total body nutrient density, and improved performance/recovery.

_________ I affirm that I am voluntarily seeking IV infusion and injection therapies at Discovery Well Being Infusion Lounge and have not been coerced into doing so.

_________ I understand the risks and benefits of the procedure, IV infusion therapy, and injection therapy and have had all my questions answered to my full satisfaction.

_________ I understand that unforeseeable complications can arise when an IV is placed and medications/fluids/minerals/vitamins are infused into the body.

_________ I understand that I have the right refuse any treatments or treatment recommendations at any time.

_________I acknowledge that there are no guarantees regarding the results of treatment and its effect on my presenting condition.

_________I give my consent for the use of emergency intervention if required during treatment.

_________I certify that I am of sound mind and body to make medical decisions and to consent for treatment.

_________I certify I will continue to remain under the care a licensed and qualified primary care provider and/or mental health provider as IV infusion and injection therapy is considered an adjunctive and non-medically necessary treatment option, not a complete one.

Treatment with IV and injectable vitamins/hydration/nutritional/mineral and/or medications offered at Discovery Well Being Infusion Lounge is completely voluntary in nature and that I am seeking out this therapy on my own or from the recommendation of my referring provider. Alternative therapy for the symptoms your seeking IV infusion and injectable therapy for include, but are not limited to, ongoing treatment by your primary care provider and/or specialty provider, oral supplementation, and dietary/lifestyle modifications.

I release all the medical staff at Summit Club, LLC, Trilogy Management, LLC and Patronus Medical from all liabilities for any complications or damages associated with IV infusion and injection therapy.

I have read this consent and fully understand the information within it, and I voluntarily authorize and consent to the treatment options, including but not limited to IV infusion therapy, provided to me by Summit Club, LLC, Trilogy Management, LLC and Patronus Medical at the Discovery Well Being Infusion Lounge.

Signature __________________________________________ Date_________________________