CONSENT PURPOSE
The purpose of this form is to obtain your consent for: Health and wellness services administered by Tayler Figgins. These services are being provided by Tayler Figgins. The reason these services are being provided is: General Health and Wellness.
NATURE OFTHESERVICES
The 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. 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-TGA EVALUATED OR APPROVED
I, as patient signing and consenting below, understand and acknowledge that the TGA has not evaluated or approved the treatments I am about to receive to diagnose, treat, cure, or prevent any disease. The TGA 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.
CONSENT
In considering all of the factors above, including risks, benefits and potential adverse results and reactions, and based on my conversations with my clinical professional about the same and alternative therapies, I hereby consent to examination, treatment, and IV therapies as listed above, including the placement of IV catheters or IM injections into and through my skin and/or veins and muscles by our medical director or the clinical professionals working under his direction.
INFORMED CONSENT
I give consent to Tayler Figgins 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 Tayler Figgins 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 Tayler Figgins’ service is self-pay only, and does not accept Medicare 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 Tayler Figgins. I desire to undergo this treatment after having considered all information and 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 Tayler Figgins 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.
SIGN
In considering all of the factors above, including risks, benefits and potential adverse results and reactions, and based on my conversations with my clinical professional about the same and alternative therapies, I hereby consent to examination, treatment, and IV therapies as listed above, including the placement of IV catheters or IM injections into and through my skin and/or veins and muscles by our medical director or the clinical professionals working under his direction. By writing and signing your name below, you acknowledge and agree that this electronic signature is just as valid and binding as a handwritten signature and you have read and agree to the terms above. You also agree that you are the person receiving the service stated above and that you are at least 18 years of age