Medical Symptom Questionnaire

This document is intended to serve as informed consent for your Intravenous (IV) Nutrient Therapy as ordered by Sayana Medical.

I have informed Sayana Medical of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed Sayana Medical of my medical history.
Intravenous infusion therapy and any claims made about these infusions 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. These IV infusions are not a substitute for your physician's medical care.
I understand that I have a right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.
I understand that: 1- The procedure involves inserting a needle into a vein and injecting the prescribed solution; 2- Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes; 3- Risks of intravenous therapy include but are not limited to: a) Occasionally: Discomfort, bruising and pain at the site of injection. b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death; 4- Benefits of intravenous therapy include: a) Injectables are not affected by stomach, or intestinal absorption problems. b) Total amount of infusion is available to the tissues. c) Nutrients are forced into cells by means of a high concentration gradient. d) Higher doses of nutrients can be given than possible by mouth without intestinal irritation.
I am aware that other unforeseeable complications could occur. I do not expect Sayana Medical to anticipate and or explain all risk and possible complications. I rely on Sayana Medical to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.
I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV Nutrient Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.

My signature below confirms that:

1- I understand the information provided on this form and agree to all statements made above.

2- Intravenous (IV) Nutrient Therapy has been adequately explained to me by Sayana Medical.

3- I have received all the information and explanation I desire concerning the procedure.

4- I authorize and consent to the performance of Intravenous (IV) Nutrient Therapy.

Patient's Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY

IV Nutrient Therapy Consent Form will be submitted to Sayana Medical Spa and Wellness Center