Disclaimer

1. I hereby give consent to Drs Mari and/ or Veldman/their associates, employees or staff, to perform prescribed intravenous administration of supplements and/ or medication.
2. I understand the benefits, and I have been informed that administration may need to be repeated from time to time in the future to maintain the benefits.
3. I understand that, I can, at any time stop this treatment protocol without incurring any further expenses after I have directed that such treatment be stopped.
4. I have been informed of possible risks and side effects including but not limited to discomfort at the injection site, allergic reactions, and other generalized complaints.
5. I agree to execute a medical release so that any previous medical records of mine of relevance may be obtained from previous physicians, and I have disclosed openly any known previous disorders.
6. I agree to keeping Drs Mari and/ or Veldman/IV Well updated of my medical conditions – should there be any interval changes between therapies, and to comply with any recommendations for testing and/ or follow up.
7. I understand that this therapy should not be used / or should be modified if I am pregnant.
8. I understand the nature of the proposed procedure and the risks and, whilst I understand that there have been no warranties, assurances or guarantees of successful treatment made to me, I desire to undergo this treatment after having considered the information contained in this document, the information provided to me and through my conversations with the treating Drs,Nurse.
9. I acknowledge that I have had the opportunity to ask any questions of my physician/s with respect to the proposed therapy and the procedures to be utilized and all my questions have been answered to my satisfaction.
10. By filling out the form below constitutes a full and final release of any legal responsibility resulting from the administration of the intravenous therapy and/or any other medical treatment that may be necessary.