MO' HYDRATIONBy NurseInjectorMo
All FormsStep 2 · Before Treatment

IV Wellness Therapy
Informed Consent

Please read each section carefully and acknowledge that you understand it. Your electronic signature at the end confirms your informed consent to treatment.

Client & Treatment

Voluntary Treatment

I voluntarily request elective IV hydration and/or nutrient therapy. I understand treatment involves placement of an IV catheter and administration of fluids and, when ordered and clinically appropriate, vitamins, minerals, nutrients, and/or medications. I may refuse or stop treatment at any time, and the provider may modify, defer, or discontinue treatment when clinically indicated.

Medical Disclosure

I certify that I have provided complete and accurate information regarding my medical history, medications, supplements, allergies, prior reactions, and pregnancy/breastfeeding status. I understand that withholding or providing inaccurate information may increase the risk of complications.

Potential Benefits & Limitations

Potential benefits may include hydration, nutrient replenishment, and general wellness support. Individual responses vary. No specific result or health benefit is promised or guaranteed, and elective IV wellness therapy is not a substitute for appropriate medical evaluation or emergency care.

Risks & Possible Complications

I understand risks may include pain, bruising, bleeding, multiple IV attempts, infiltration/extravasation, phlebitis, infection, hematoma, dizziness/fainting, nausea, fluid or electrolyte imbalance, fluid overload, changes in blood pressure or blood glucose, medication/nutrient side effects or interactions, allergic reaction, and rare severe reactions including anaphylaxis. Ingredient-specific risks and contraindications may also apply.

Alternatives

Alternatives may include oral hydration, oral vitamins/supplements, diet, rest, evaluation by another healthcare professional, or no treatment.

Medications / Optional Additives

Prescription medications or optional additives are administered only when ordered and clinically appropriate. Ingredients may be modified or withheld based on assessment, allergies, medications, contraindications, availability, or clinical judgment.

Emergency / Aftercare

I agree to report concerning symptoms immediately. If a significant reaction or emergency occurs, treatment may be stopped and emergency medical services may be activated. Severe or emergent symptoms require 911 or emergency-department evaluation. I agree to follow aftercare instructions and seek evaluation for persistent or worsening symptoms.

Acknowledgment

By signing below, I confirm that I have had the opportunity to ask questions; the nature, potential benefits, material risks, and reasonable alternatives have been explained to me; I understand no outcome is guaranteed; and I voluntarily consent to the treatment agreed upon with my provider. This consent does not waive my legal rights or relieve a healthcare professional of the duty to meet applicable standards of care.

Electronic Signature

By typing your full legal name below, you acknowledge this serves as your electronic signature and confirms your voluntary informed consent to the treatment agreed upon with your provider.

Please acknowledge all 8 sections above to enable your signature.

IV wellness services are elective and subject to individualized clinical assessment. Medical information and treatment records will be maintained in accordance with applicable privacy and recordkeeping requirements.

Replenish. Recover. Refresh. — By NurseInjectorMo

MO' Hydration provides elective IV hydration and wellness services. These services are not intended to diagnose, treat, cure, or prevent any disease and do not replace emergency or primary medical care. All treatment is based on an individualized clinical assessment. Individual responses vary and no specific result or health benefit is guaranteed. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.