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.
