I understand that intravenous therapy and any claims made about these infusions
have not been evaluated by the U.S Food and Drug Administration and are not intended to
diagnose, treat, cure, or prevent any medical disease. Infusions are not a substitute for your
primary physician’s medical care.

For today’s procedure:
1. I understand that intravenous infusion involves the insertion of a needle into a vein and
injection of the prescribed solution.
2. I understand possible alternatives to IV Therapy include but are not limited to oral
supplements and/or dietary and lifestyle changes.
3. I understand the risks of IV Therapy include but are not limited to:
a) Occasional discomfort, bruising, and possible pain at the injection site
b) Rare inflammation of the vein used during the infusion, phlebitis, and metabolic
disturbances.
c) Extremely rare allergic reactions, anaphylaxis, infection, cardiac arrest and death.
4. I understand other unforeseen complications could occur.
5. I do not expect the Elite IV, PLLC to anticipate and/or explain all risks and possible
complications of intravenous infusions.
6. I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered.
7. I understand I have the right to consent to or refuse any proposed/offered therapy, at any
time prior to its administration.

By signing below, I acknowledge that I have been provided access to a copy of ELITE IV,
PLLC’s Notice of Privacy Practices.
I understand the information provided on this form and agree to all statements made above, all
procedures have been adequately explained to me, and I authorize and consent to the
performance of procedures.
I release ELITE IV, PLLC including its providers and employees from all liabilities from any
complications or damages associated with intravenous infusion therapy.