*** If you have already filled out the Medical Questionnaire you may skip, unless something has changed in your medical history ***

*** If you have already filled out the Covid-19 Questionnaire you may skip, unless something has changed in your medical history ***

This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health. Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the doctors and other health professionals at Fomwellness & Ivhydration LLC, as is appropriate and necessary for my care. I understand that I may suspend or terminate my treatment at any time by informing my medical provider. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment to the fullest extent allowed by law. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated. I hereby place myself under your care for intravenous vitamin and/or hydration therapy, and agree to the above release. I also verify that all information presented to you in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment for these conditions. I hereby acknowledge that I understand that my Insurance coverage, including Medicare, will not be billed and will not pay for this Non-covered service, and that all services ancillary to this treatment will be also Non-covered services and Non-reimbursable. I agree to be responsible for payment.

This document is intended to serve as informed consent for your Intravenous (IV) infusion Therapy or your Intramuscular Injection(s) as prescribed by the medical staff at Fomwellness & Ivhydration LLC. You will need to sign after reading below. I have informed the nurse practitioners or nurse of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the staff of my complete medical history. Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician’s medical care. 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. I understand the following: 1. The procedure involves inserting a needle into a vein and injecting the prescribed solution. Intramuscular injections involve inserting a needle into a large muscle and injecting the solution. 2. Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes. 3. Risks of intravenous therapy include but are not limited to: a. Occasionally: Discomfort, pain, and burning 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, cardiac arrest, death, air embolism, fluid overload, medication adverse interactions, and nerve injuries. 4. Benefits of intravenous therapy include: a. Injectables are not affected by stomach or intestinal absorption problems. b. Total amount of the infusion is available to the tissues. c. Nutrients are forced into cells by means of a high concentration gradient. d. Higher doses of nutrients can be given than possible by mouth without intestinal irritation. I am aware that other unforeseeable complications could occur. I do not expect the nurse practitioners, nurses, and or physician to anticipate and or explain all the risk and possible complications. I rely on the nurse practitioners, nurses, and or physician to exercise judgement 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. My signature on this form affirms that I have given my consent to IV infusion therapy including any other procedure which, in the opinion of my health care provider may be indicated. My signature below confirms that: 1. I understand the information provided on this form and agree to all the statements made above. 2. Intravenous (IV) Infusion Therapy has been adequately explained to me by the provider at Fomwellness & Ivhydration LLC. 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) Infusion Therapy. 5. I release Fomwellness & Ivhydration LLC, and all the medical staff from all liabilities, complications, or damages associated with my Intravenous (IV) Infusion Therapy.

I EXPRESSLY REPRESENT AND WARRANT TO Fomwellness & Ivhydration LLC THAT I AM NOT A USER OF ILLEGAL DRUGS AND/OR CONTROLLED SUBSTANCES (OTHER THAN THOSE LAWFULLY PRESCRIBED TO ME AND WHICH I HAVE FULLY DISCLOSED TO Fomwellness & Ivhydration LLC) AND AM NOT UNDER THE INFLUENCE OF SAME OR RECOVERING FROM USE OF SAME AT THE TIME OF THE PROVISION OF SERVICES TO YOU. IN THE EVENT OF AN EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM. ACKNOWLEDGMENT: I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by Fomwellness & Ivhydration LLC. I understand the nature of the sessions and programs and that participating in them carries risks. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction. I agree to my assumption of all risks associated with my participation. Medical Professional Certification. I hereby certify that I have explained the nature, purpose, benefits, risks of, complications from, alternatives to (including no participation by the client and any attendant risks), the proposed regimen, sessions and programs, have offered to answer any questions and have fully answered all such questions. I believe that the client/agent/relative/guardian fully understands what I have explained.

DISCHARGE INSTRUCTIONS FOR INTRAVENOUS (IV) INFUSION THERAPY: How to care for yourself after your IV Infusion Apply pressure to site for 2 minutes after IV has been removed. Keep Band Aid in place for 1 hour. Warm packs and elevating your arm can be used for any bruising at the site. Cold packs can be used for pain relief and to decrease any swelling at the site. Any swelling should be significantly reduced in 24 hours. Post IV infusion symptoms are uncommon. Most patients experience significant overall improvements: Better energy Better mental clarity Improved sleep Overall sense of well being

Patients generally feel better right away. Due to a busy lifestyle, many people are chronically dehydrated and deficient in vitamins and minerals causing them not to feel well. Once the patient is hydrated and the nutrients are replaced, their symptoms improve quickly. Patients sometimes feel unwell or tired. These patients are generally in the process of detoxifying. When toxins are pulled out of tissues, they re-enter the bloodstream. They remain poisons, but are now on their way OUT instead of on their way IN. Even when patients do not feel well at this stage, the process is one of healing and cleansing. After this period, an overall improvement in one’s sense of wellbeing is generally reported.

If any of the following are progressively worsening after your IV infusion: Significant swelling over the IV site Redness over the vein that is increasing in size Pain in the vein/arm that is not improving over an 8-12 hour period Headache that does not resolve with increased hydration or over-the-counter pain relievers such as Advil or Tylenol