IV THERAPY CONSENT

I understand that Age Well Dr. does not provide healthcare services and will book an appointment for the selected procedure(s) to be performed by a medical provider (the "Medical Provider") licensed to perform such procedures in the State where the procedures are performed. I understand that Age Well Dr. will share the preceding medical history with the Medical Provider who will confirm the appropriateness of the procedure(s) and will perform and/or oversee the procedure(s) in their professional medical discretion. I certify that the preceding medical, medication and personal history statements including those previously disclosed and stated are true and correct. I am aware that it is my responsibility to inform Age Well Dr. the Medical Provider of my current medical or health conditions and to update this history, as necessary. A current medical history is essential to execute appropriate treatment procedures.

I. PURPOSE OF IV THERAPY

I understand that intravenous (IV) nutrient therapy involves the administration of vitamins, minerals, amino acids, and/or other nutrients directly into my bloodstream through an IV line. The purpose of IV therapy is to promote health, restore nutritional balance, enhance recovery, and support wellness goals such as improved energy, hydration, and immune function.

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II. DESCRIPTION OF PROCEDURE

1. A small IV catheter will be inserted into a vein in my arm or hand.
2. A sterile solution containing nutrients, electrolytes, and/or medications will be slowly infused over approximately 30–90 minutes.
3. My vital signs and comfort level will be monitored during the procedure.
4. Once completed, the IV will be removed and a bandage applied.

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III. POTENTIAL BENEFITS**

I understand that potential benefits of IV therapy may include:

* Improved hydration and energy levels
* Enhanced immune system function
* Reduced symptoms of fatigue, jet lag, and stress
* Faster recovery from illness, workouts, or dehydration
* Improved mental clarity and mood

However, **Age Well LLC** and **Age Well Dr LLC** make **no guarantee** regarding the success of any treatment.

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IV. RISKS AND POSSIBLE SIDE EFFECTS**

I understand that, while IV therapy is generally safe, risks and side effects may include:

* Pain, redness, or bruising at the injection site
* Infection at the IV site
* Vein irritation or inflammation (phlebitis)
* Allergic reaction to ingredients
* Dizziness, nausea, or lightheadedness during or after infusion
* Infiltration (fluid leakage into surrounding tissue)
* Rare but serious complications, such as fluid overload or anaphylaxis

If I experience any unusual symptoms during the infusion, I agree to immediately notify the attending provider or staff member.

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V. MEDICAL HISTORY DISCLOSURE**

I affirm that I have disclosed my **complete medical history** to my provider, including:

* Current medications and supplements
* Allergies (especially to medications, vitamins, or minerals)
* Any history of kidney, heart, or liver disease
* Pregnancy or breastfeeding status
* Any other relevant medical condition

I understand that failure to disclose complete and accurate information could increase my risk of adverse effects.

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VI. ALTERNATIVE TREATMENTS**

I understand that alternatives to IV therapy include oral supplementation, dietary modification, hydration, and rest. I have chosen IV therapy voluntarily and acknowledge that it may be used in conjunction with, but not as a substitute for, medical diagnosis or treatment by a licensed physician.

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VII. CONSENT TO TREATMENT**

I voluntarily consent to receive IV nutrient therapy from the licensed providers and staff of **Age Well LLC** and **Age Well Dr LLC**.
I acknowledge that:

* No specific results have been promised.
* I may withdraw consent and discontinue treatment at any time.
* I am financially responsible for all services rendered.

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VIII. RELEASE OF LIABILITY**

By signing below, I release and hold harmless **Age Well LLC**, **Age Well Dr LLC**, its owners, employees, medical providers, and contractors from any liability for adverse reactions or outcomes that may occur as a result of IV therapy, except in cases of gross negligence or willful misconduct.

I have had the opportunity to ask questions about this procedure and all of my questions have been answered to my satisfaction.

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IX. FINANCIAL AGREEMENT**

I understand that IV therapy is considered an **elective wellness service** and is **not covered by insurance**.
Payment is due at the time of service unless otherwise agreed.
I acknowledge that **no refunds** are issued once services are rendered or solutions prepared.

IV Stem Cell and Exosome Consent


I. INTRODUCTION

This consent form is designed to help you make an informed decision about receiving stem cells derived from donated human umbilical cord tissue, and/or exosomes derived from donated human amniotic fluid. These stem cells and/or exosomes are processed in accordance with the regulatory standards contained in Florida Statute §459.0127 (CS/CS/SB 1768 (2025)) (hereinafter “Florida Statute”) and are used for the therapeutic purposes permitted by this statute. The purpose of this form is to ensure you fully understand the nature, risks, and alternatives before proceeding with the proposed stem cell treatment.

II. FDA STATUS

This physician performs one or more stem cell/exosome procedures that have not yet been approved by the United States Food and Drug Administration (FDA). You are encouraged to consult with your primary care provider before undergoing any stem cell therapy.

Accordingly, you acknowledge and understand that the Stem Cell/Exosome procedure being offered is not approved by the U.S. Food and Drug Administration.

III. WHAT ARE UMBILICAL CORD STEM CELLS?

Umbilical cord stem cells are obtained from the Wharton's Jelly found in the umbilical cord after healthy, full-term births take place. Donors are pre-screened and tested according to FDA regulations to reduce the risk of communicable diseases. These cells are not embryonic and are considered ethically sourced from postnatal tissue, as required by Florida Statute.

IV. WHAT ARE AMNIOTIC FLUID-DERIVED EXOSOMES?

Exosomes are allogeneic product is a derivative of full-term human amniotic fluid (HAF), a secreted body fluid or non-HCT/P. The product is an allogeneic, perinatal tissue-derived Human Cells, Tissues, and Cellular and Tissue-Based Product (HCT/P) containing Human Amniotic Fluid. This product is acellular and contains naturally occurring paracrine factors such as, but not limited to, cell-derived nanoparticles and exosomes.

V. PURPOSE OF TREATMENT

The purpose of this procedure is to support the body’s natural healing processes and reduce symptoms related to:

Orthopedic or musculoskeletal conditions
Pain
Wound healing

While some studies suggest potential benefits in reducing inflammation or promoting regeneration, this Stem Cell/Exosome procedure is not FDA-approved for the treatment or cure of any specific disease or condition.

VI. POSSIBLE BENEFITS

Potential benefits of this Stem Cell/Exosome procedure may include:

Improved function or mobility
Reduced inflammation
Reduced pain
Support of natural healing processes and enhanced wound healing

However, these benefits are not guaranteed, and outcomes may vary based on individual factors. Additionally, the therapeutic or palliative effects may have a limited duration and may require additional treatments in the future.

VII. RISKS AND SIDE EFFECTS

As with any treatment, there are potential risks with Stem Cell/Exosome procedures. These may include, but are not limited to:

Bleeding or bruising at the injection site
Pain or swelling
Infection
Allergic or immune reaction
No improvement or worsening of the condition
Unknown or unforeseen complications

While umbilical cord stem cells are processed and screened for safety, there is a small risk of transmission of infectious agents or an immune reaction.

VIII. CONTRAINDICATIONS

You should not undergo this procedure if any of the following apply:

Pregnant or breastfeeding
History of severe allergic reactions (unless cleared by a physician)
Active systemic infection, fever of unknown origin, or local infection at the injection site
Active cancer, metastatic disease, currently undergoing chemotherapy/radiation, or a remote history of cancer within the past 5 years for stem cells and 2 years for exosomes (unless cleared by a physician)
Recent thrombotic or cardiac event within the past 6 months (stroke, myocardial infarction, DVT, PE), or an uncontrolled hypercoagulable disorder
Hemodynamic instability, uncontrolled arrhythmia, or decompensated heart failure
IX. ALTERNATIVES

You have the option to decline this treatment. Other treatment options may include physical therapy, FDA-approved medications, surgery, or no treatment at all. You are encouraged to discuss all treatment options with your primary care physician.

X. PRIMARY CARE CONSULTATION ENCOURAGED

You are encouraged to consult with your primary care physician or specialist before proceeding with this Stem Cell/Exosome procedure. This is an important step in making a well-informed medical decision.

XI. CONFIDENTIALITY

Your personal health information and any data collected during this treatment will be kept confidential and used only for clinical or research purposes as allowed by Florida and Federal law.

XII. VOLUNTARY PARTICIPATION

This procedure is completely voluntary, and you may withdraw your consent at any time without affecting your right to future care or treatment.

XIII. CONSENT ACKNOWLEDGMENT

By signing below, you confirm that:

You have read and understand the content of this consent form.
You have had the opportunity to ask questions, and they have been answered to your satisfaction.
You have had the opportunity to discuss this Stem Cell/Exosome procedure and alternative therapies with your primary care physician.
You understand the risks and benefits, and voluntarily agree to receive the Stem Cell/Exosome procedure comprised of umbilical cord-derived stem cells, and/or HAF exosomes.
. CONSENT ACKNOWLEDGMENT

By signing below, you confirm that:

You have read and understand the content of this consent form.
You have had the opportunity to ask questions, and they have been answered to your satisfaction.
You have had the opportunity to discuss this Stem Cell/Exosome procedure and alternative therapies with your primary care physician.
You understand the risks and benefits, and voluntarily agree to receive the Stem Cell/Exosome procedure comprised of umbilical cord-derived stem cells, and/or HAF exosomes.