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I understand the information in this form is gathered to make my IV Therapy/Injection therapy as safe as possible. I  understand that a peripheral intravenous catheter will be inserted into a vein to directly give my body fluid along with medications, vitamins, minerals, nutrients (discussed and decided with my IV provider. This is considered “IV Infusion Therapy.” If I am having injection therapy, then I understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of my body. This is considered “Injection Therapy.”

By singing this consent I agree to the following:

-I attest that the information I have provided is true and complete to the best of my knowledge

-I consent to receive IV hydration infusions and/or IV injections from Moderni Spine PLLC

-I understand that I am responsible for any charges incurred in the course of my treatment.

-I understand that my deposit of $50 is non-refundable unless I cancel prior to 24 hours. 

-I release the Registered Nurse providing me this service, from any and all liability from problems arising from the treatment as a result of information not given or incorrectly given in the patient history. My personal and medical information is confidential, and I understand that none of this information will be shared with any third parties, unless my consent is given in writing.

1. I understand that IV infusion and injection therapy at Moderni Spine PLLC is not intended to diagnose or treat a specific medical condition.

2. I understand that IV infusion and injection therapy will not prevent, treat, or cure any medical condition or disease. Furthermore, I understand that I am here seeking IV infusion and/or injection therapy voluntarily to assist with certain symptoms or ailments I may be experiencing.

3. I have informed Moderni Spine PLLC and their staff of all the medications, supplements, health conditions, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all of my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.

4. I understand that IV and injectable therapy and any claims made about these treatments have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. I understand that these treatments are not FDA approved for any given indications of treatment and are not considered a medical necessity.  

5. I understand that I have been informed of the procedure involving IV infusion and injections, the alternative treatment options, and the risks and benefits of the mutually agreed upon treatment.

6.  I understand that the procedure involves inserting a needle into a vein and administering fluids and vitamins/minerals or having a solution injected into my muscle or body fat.

7. I understand that common risks involved with IV and injection therapies include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the IV insertion or injection.

8. I understand that less common risks involved with IV and injection therapies include, but are not limited to, infection at the site of the IV insertion or injection, injury to the tissue, phlebitis, low blood pressure, fainting, fluid volume overload, medication interactions, and drops in blood sugar levels.

9.  I understand that rare side effects involved with IV and injection therapies include, but are not limited to, sepsis, severe allergic reactions, severe medication/supplement interactions, anaphylaxis, blood clots, shock, cardiac arrest, and death.

10. I understand the risks and benefits of the procedure, IV infusion therapy, and injection therapy and have had all my questions answered to my full satisfaction. I acknowledge that I have been given sufficient information about IV hydration/vitamin/mineral/nutrient infusion and injection therapy and all its associated risks and benefits upon which to make an informed decision about treatment.

11. I understand that I have the right refuse any treatments or treatment recommendations at any time.

Voluntary Nature of Treatment and Alternative Therapies

Treatment with IV and injectable vitamins/hydration/nutritional/mineral and/or medications offered from Moderni Spine PLLC is completely voluntary in nature and that I am seeking out this therapy on my own or from the recommendation of my referring provider. I acknowledge that I have notified my medical health provider about my decision to undergo IV and injectable vitamin/hydration/nutritional/mineral therapy or assume risks. I acknowledge that there are no guarantees regarding the results of treatment and its effect on my presenting condition.

·        I give my consent for the use of emergency intervention if required during treatment.

·        I certify I will continue to remain under the care a licensed and qualified care provider as IV infusion and injection therapy is considered an adjunctive and non-medically necessary treatment option.

·        I release Cynthia Konrath PA-C, Moderni Spine PLLC, and all employees and staff, and affiliated entities from all liabilities for any side effects, complications, physical injury, damages, or otherwise associated with IV infusion and injection therapy.

·        I have read this consent and fully understand with sound mind and body the information within it and I voluntarily authorize and consent to the treatment options, including but not limited to IV infusion therapy or injection therapy, provided to me from Moderni Spine PLLC.