Patient Intake Form

I hereby give consent to Blessed hands IV Hydration & Wellness LLC - BHIV to perform intravenous vitamin and mineral therapy. I understand that intravenous nutrient therapy is not standard, widely approved or accepted for the purpose(s) of treatment of prevention of disease and the view that it is of benefit in the treatment of such disorders is accepted by a minority of the medical community and is considered "experimental" by most medical providers. I am advised that other treatment approaches have been used in these conditions, including but not limited to prescription medications, over-the-counter drugs and nutritional supplements and these alternatives have been explained to my full satisfaction. I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, proper exercise, proper diet and nutritional supplementation). I understand that an initial series of treatments are anticipated and that these treatments may extend over several weeks or months. I understand that it is my option to stop at any time with this treatment protocol without incurring any further expense after I have directed that such treatment be stopped. 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 at the infection site, thrombophlebitis, fatigue, allergic reaction, congestive heart failure, lowering of blood sugar levels, fever, and chills and generalized complaints. I understand that this therapy should not be used if I am pregnant since not enough research has been found. I do not expect the persons employed or associated with BHIV to anticipate and or explain all risk and possible complications. I understand the nature of the proposed therapy and the risks and dangers have been explained to me to my full satisfaction. While I understand that there have been no warranties 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 through conversations and materials that may be provided to me by the office to educate me about the treatment. I acknowledge that I have had the opportunity to ask questions and with respect to my proposed therapy and the treatments to be utilized and all my questions have been answered to my full satisfaction. I consent to all nutrient injections rendered by Blessed Hands IV Hydration LLC (BHIV)- Lucky Keonavong Robinson AGPC-NP-C and medical staff. I understand that nutrient injections may not be approved by the USFDA for treatment of my medical condition. My acknowledgement on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of intravenous nutrient therapy in my case and/or any other medical treatments that may be necessary as a result thereof.