Consent for Services
INFORMED CONSENT FORM FOR HEALING HYDRATION LLC AND AUBREY COTHAM, R.N.
This document is your Informed Consent form for IV therapy and treatment as
administered by Healing Hydration LLC, and Aubrey Cotham, R.N. By signing this form, you
understand that you have the right to be informed about the procedure, and about the risks
and benefits of the procedure. Except in emergencies, procedures are not performed until you
have had an opportunity to receive such information and to give your informed consent. The IV
intravenous procedure involves inserting a needle into your vein and infusing over a
determined period of time, prescribed nutrients (vitamins, minerals, amino acids). As with any
medical procedure, there are risks and potential side effect that you should be aware of. It is
also important that you be aware of the benefits of IV therapy.
You understand that risks, benefits and alternatives to IV therapy may include but are
not limited to:
1. The risks and potential side effects:
• Discomfort, bruising, and pain at the site of injection.
• Inflammation of the vein used for injection, phlebitis, infiltration, metabolic disturbances, and
injury.
• Severe reaction, anaphylaxis, cardiac arrest, or death.
2. The Benefits:
• lnjectables are not affected by stomach or intestinal disease.
• Total amount of infusion enters the bloodstream and is available to be used by the body
• Higher doses of nutrients can be given by vein than by mouth without intestinal
irritation that can accompany doses given by mouth.
3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and
lifestyle changes.
You understand and agree that other unforeseeable complications could occur from this
therapy. You understand the risks and benefits of the procedure and have had the opportunity
to have all of your questions answered. You understand that you have the right to consent to or
refuse any proposed treatment at any time prior to its performance. Your signature on this
form affirms that you have given your consent to IV therapy and are accepting and assuming
the risks associated with such procedure.
I understand the information provided on this form and
agree to the foregoing. I understand that there is no implied or stated guarantee of success or
effectiveness of any treatment. The procedure(s) set forth herein has been adequately
explained to me by Healing Hydration LLC. I understand that I am free to withdraw my consent
and to discontinue participation in this treatment at any time. I understand that, except in
emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment. I
understand that I will incur the full fee for treatment regardless of amount used due to wasted
materials.
My signature below confirms that:
1. I have received all the information and explanation I desire concerning the procedure.
2. I authorize and consent to the performance of the procedure(s).
3. I have informed Healing Hydration LLC of any and all known allergies to drugs or other
substances that may be included in the ingredients of my solutions, or of any past
reactions to anesthetics.
4. I have fully informed Healing Hydration LLC of all current medications and supplements.
5. I have fully informed Healing Hydration LLC of all current physical ailments and
conditions.
_____________________________
Patient
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