I consent to the insertion of a peripheral intravenous catheter and to the infusion of fluids, vitamins, mineral and/or compounded cofactor, and/or medications. I agree and acknowledge that no promises or guarantees were made regarding the efficacy of the infusion. Further, I acknowledge that statements regarding vitamin and mineral infusions have not been evaluated by the FDA and that the infusion of such has no diagnostic value nor is the infusion a substitute, cure, therapy, or treatment for any disease or condition.

I understand that the infusion is being carried out under the direction of Monelle Burrus FNP-c and by a nonphysician who is trained in the safe insertion, monitoring, stabilization, and removal of intravenous catheters and infusions. If at any time, a determination is made that the procedure or infusion is outside of the conditions of safety, it may be discontinued.

I have informed the nurse and/or provider of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or provider of my medical history.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

1. The procedure involves inserting a needle into a vein and injecting the prescribed solution.

2. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.

3. Risks of intravenous therapy include but not limited to:

a. Occasionally: Discomfort, bruising and pain at the site of injection.

b. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

c. Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.

I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or providers(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or providers(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

Payment is due at the time of service. There has been no representation that this procedure is covered under my insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless if the infusion cancelled or is stopped at any time prior to completion at the discretion of the technician/nurse/clinical assistant or myself.

Your right to privacy in this medical practice is paramount and we will never disclose any of your personal information without your express consent, unless required to do so by law. This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. Please read it carefully. The Physician will acquire private information about their patients. This is confidential and will not be discussed outside the office, except that the Physician may discuss patients with other healthcare professionals in terms that do not allow identification of the individual. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment. Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts, or contact by alternative means. Additionally, we may be required to disclose your health information in the following circumstances: In the event of an emergency; if required by law; if there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care; if ordered by the courts, government authorities, public health, law enforcement, coroners, or funeral directors; in the event of organ donations, research, military activity, or for national security.

By signing you give Verve Health LLC consent to communicate with you through text, phone, or email. This consent will allow for scheduled appointment reminders, refill requests and other communications to be sent and received via text, phone and/or email. This consent may be revoked at any time with written notice to Verve Health LLC.

1. I understand the information provided on this form and agree with all statements made above.

2. Intravenous (IV) Therapy has been adequately explained to me by my nurse and/or my prescribing provider.

3. I have received all the information and explanation I desire concerning the procedure.

4. I authorize and consent to the performance of Intravenous (IV) Therapy.

5. I understand payment is due at the time of service.