Consent & patient history

CONSENT

INFORMED CONSENT ADVANCED MOBILE IV

I give consent to Advanced Mobile IV to administer vitamins, minerals, medications, and other nutrients via injection and/or intravenously. I understand that intravenous nutrient therapy is not approved or accepted for the purpose(s) of treatment or prevention of disease. I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, exercise, and proper diet). I have informed Advanced Mobile IV of all of my current medications and supplements that I am taking as well as any health problems and allergies. As with any other medical procedure, a small percentage of clients do not respond to this therapy. I have been informed of possible risks and side effects including but not limited to discomfort and bruising at the injection site, infection, bleeding, thrombophlebitis, fatigue, congestive heart failure, metabolic disturbances, anaphylaxis, cardiac arrest, or death. I understand the nature of the proposed therapy and the risks involved have been explained to my full satisfaction. Benefits of intravenous therapy include nutrients bypassing the stomach and not being disturbed by intestinal absorption. This process allows nutrients to be available to the tissues by means of a high concentration gradient. I understand that this treatment is voluntary and I may terminate it at any time. I acknowledge that Advanced Mobile IV is self-pay only, and does not accept Medicare, Medicaid, or any other private insurance. I am responsible for full payment at the time of service or otherwise agreed by previous arrangements between myself and Advanced Mobile IV. I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations, and materials that may be provided to me for education. I acknowledge that I have had the opportunity to ask questions, and all of my questions have been answered to my full satisfaction. My agreement will constitute a full and final release of any legal responsibility of Advanced Mobile IV and all associated before, during, and following my treatment, and in my case and/or any other medical treatments that may be necessary as a result thereof. My agreement confirms that I am 18 years of age or older, and of sound mind. I have read, understood, and agree to this consent, and to receive treatment. All of my questions have been answered to my full satisfaction.

PURPOSE

The purpose of this form is to obtain your consent for: Health and wellness services administered by Advanced Mobile IV and its affiliates. These services are being provided by: Advanced Mobile IV and its affiliates. The reason these services are being provided is: General Health and Wellness.

NATURE OF THE SERVICES

The Advanced Mobile IV services consist of infusions into my body through IV drip or IM injection, of minerals, vitamins, and/or other nutrients suspended in a liquid form. A needle and or a needle and a catheter will be inserted through my skin either into a muscle or a vein in order to introduce this liquid into my body.

WEIGHT LOSS

I understand that my program may consist of a balanced-deficit diet, a regular exercise program, instruction on behavior modification techniques, and may involve the use of anti-obesity medications. I further understand that if medications are used, they have been used safely and successfully in private medical practices with experienced obesity medicine specialists as well as in academic centers for periods exceeding those recommended in the product literature. I understand that much of the success of the program will depend on my efforts and that there are no guarantees that the program will be successful.

RISKS, BENEFITS AND ALTERNATIVES

The benefits of the Services include potentially: increased energy, hydration, increase in metabolism, cardiovascular support, nail, skin and hair health, and immune-system support. The risks include: (i) injection/venipuncture site swelling, redness, irritation, bruising, bleeding, and infection, (ii) reaction to vitamins including fever, aches, nausea, rash, hives, wheezing, joint swelling, and general allergic reaction, and (iii) other minor complications of IV or IM injection.

NON-FDA EVALUATED OR APPROVED

I, as patient signing and consenting below, understand and acknowledge that the United States Food and Drug Administration has not evaluated or approved the treatments I am about to receive to diagnose, treat, cure, or prevent any disease. The FDA might in fact recommend other treatments.

JUDGMENT AND CHANCE TO ASK QUESTIONS

In giving the consent hereunder, I, as patient, am relying on the judgment of the clinical professional evaluating me and administering the treatments. I have had the meaningful chance to ask questions and have received satisfactory answers to my questions. The risks and potential benefits of the treatment I am consenting to have been explained to me. Alternatives to the treatments I am consenting to have also been discussed with me.

MEDIA RELEASE

I hereby grant permission to Advanced Mobile IV to use photographs and/or videos obtained from me for advertising purposes.

REPRESENTATION OF NON-PROFESSIONAL ATHLETE STATUS

I hereby represent and warrant that I am not a professional athlete. For the purposes of this document, a "professional athlete" is defined as an individual who is paid to participate in sports or athletic events as their primary occupation. This includes, but is not limited to, athletes participating in leagues, tours, or competitions recognized as professional by relevant sports governing bodies. By signing this document, I confirm my status as a non-professional athlete. I acknowledge that providing false information regarding my status may result in personal liability for any incidents arising from the treatment.