ELEMENTZ WELLNESS

Please complete all sections. Select N/A if an item does not apply to you.

I acknowledge that I have reviewed the IV Vitamin Hydration Therapy Informed Consent provided above and understand the nature of the treatment, potential benefits, risks, side effects, alternatives, and contraindications.

I acknowledge that I have reviewed the Intramuscular Injection Informed Consent provided above and understand the nature of the treatment, potential risks and side effects, alternatives, and that results are not guaranteed.

By signing below, I acknowledge that the information I have provided is accurate and complete to the best of my knowledge. I understand that I should inform my practitioner of any changes to my medical history, medications, allergies, pregnancy status, or other information relevant to treatment before receiving future services. I acknowledge that I have reviewed the applicable informed-consent information above, have had the opportunity to ask questions, and voluntarily consent to the treatment(s) selected.