Name: Chicago IV Solution
Telephone: 844.948.6337
Price range: $

IV Solution Centers

INFORMED CONSENT FOR NAD+ AND VITAMIN INFUSION THERAPY

Before you participate in NAD+, vitamin, mineral or nutrient infusion therapy, it is important that you completely understand the procedure, its benefits, and its risks. Please understand that the procedure is voluntary and that you have the right to stop at any time. Read the below statements carefully and initial in the space provided. Then read the final statement and sign and date this consent
Therapy
- This procedure is recommended for replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as anti-aging, improving depression/anxiety, improving immune function, improving antioxidant status, reducing oxidative damage, improving fatigue/concentration, etc.
- I understand and agree to adhere to the treatment schedule and attend the follow-up visitations set by my medical provider to permit observation and study of my progress.
- 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.
- The principal side effects that may accompany intravenous administration of nutrients include:
  – burning and stinging at the site of infusion or if IV infiltrates into surrounding tissue
  – muscular spasms, weakness, mild headache, or fatigue
  – allergic reactions (rare)-local thrombophlebitis (very rare).
- The risks involved, and the possibilities of complications have been explained to me.
- I have been explained thoroughly about the use of intravenous NAD+ and I had the opportunity to ask all the relevant questions I felt necessary.
- I understand that I can revoke this consent at any time including during the infusion.
Patient Name*
Signature (Patient)
Date
MM slash DD slash YYYY
Signature (Witness)
Date
MM slash DD slash YYYY

IV Solution Centers

INFORMED CONSENT FOR NAD+ AND VITAMIN INFUSION THERAPY