CONSENT AND DISCLAIMER FORM FOR IV THERAPY

This Consent and Disclaimer Form is intended to inform you, the patient, about the nature, purpose, risks, and benefits of Intravenous (IV) Therapy. By signing this form, you acknowledge and accept the terms outlined below and assume full responsibility for your decision to proceed with IV Therapy.

Patient Information

Full Name *

Date Of Birth *

Address *

Phone *

Email *

Acknowledgement of IV Therapy Purpose and Process

I, the undersigned, understand that:

• IV Therapy involves the administration of fluids, vitamins, minerals, and/or medications directly into the bloodstream through an intravenous line.

• The purpose of IV Therapy is to support hydration, nutrient delivery, and overall wellness. The benefits of the therapy vary based on individual health conditions and needs.

• IV Therapy is not intended to diagnose, treat, cure, or prevent any disease. It is a complementary therapy and should not replace conventional medical treatments.

Risks and Side Effects

I acknowledge that IV Therapy may involve certain risks, including but not limited to:

• Mild discomfort, bruising, or swelling at the injection site.

• Temporary dizziness, nausea, or light-headedness.

• Rare risks, including allergic reactions, vein irritation (phlebitis), or infection at the injection site.

• Any underlying or pre-existing conditions may influence the therapy’s effectiveness or risks involved.

I confirm that I have disclosed my full medical history, including any allergies, current medications, or medical conditions, to the healthcare provider administering the IV Therapy.

Patient Responsibility and Disclaimer

By signing this form, I accept the following:

• I am fully responsible for my decision to undergo IV Therapy. I understand that no guarantees or warranties have been made regarding the results or outcomes of the therapy.

• I acknowledge that the healthcare provider has explained the procedure, potential benefits, and associated risks, and I have had the opportunity to ask questions and receive satisfactory answers.

• I release Marylebone Diagnostic Centre, its staff, and healthcare providers from any liability or claims arising from my decision to undergo IV Therapy, except in cases of gross negligence or wilful misconduct.

• I accept that 100% of the responsibility for my health, including any outcomes from this therapy, lies with me, the patient. I will not hold the clinic or its staff accountable for any adverse effects unless explicitly proven to be caused by negligence.

Consent to Proceed

I have read and fully understand the information provided in this form. I voluntarily agree to proceed with IV Therapy, assuming full responsibility for my decision. I confirm that I have disclosed all relevant medical information and that I am aware of the potential risks and benefits of the procedure.

Name *

Date *

Healthcare Provider Declaration

I confirm that I have explained the IV Therapy procedure, its purpose, potential benefits, and associated risks to the patient. I have answered all questions to the best of my ability, ensuring the patient’s understanding and consent.

Name *

Date *