DRIP | IV BAR AT RENEW

I hereby authorize the following procedure: administration of intravenous vitamins, minerals, and other nutrients.

This procedure is recommended for the replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, decreasing bronchospasm, improving fatigue, etc. I expressly represent and warrant to (Your practice) that I have never been diagnosed with, nor treated for any diseases, illnesses, or conditions that may result in increased risk when I participate in regimens, programs, or services made available by Renew Medical Spa, Laser and Wellness, LLC and I am choosing not to participate with any expectation that Renew Medical Spa, Laser and Wellness will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.

The procedure involves inserting a needle into your vein and injecting the medicine/additives prescribed by your provider (ie. Physician/NP/PA) The principal side effects that may accompany intravenous administration of nutrients include: The principal side effects that may accompany intravenous administration of nutrients include:

-burning/stinging, bleeding, infection, swelling, and/or scarring at the site of infusion or if IV infiltrates into surrounding tissue

-muscular spasms, weakness, or fatigue, nerve injuries, fluid overload

- light-headedness and/or fainting, allergic reactions (rare),

- local thrombophlebitis, anaphylaxis, cardiac arrest, and death (very rare)

This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health.

Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the health professionals at Renew Medical Spa, Laser and Wellness LLC as is appropriate and necessary for my care.

I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I

may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated. I acknowledge no guarantees have been made concerning the results intended from this procedure and that participating in them carries risks. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction.

I hereby place myself under your care for intravenous vitamin therapy and agree to the above release. I also verify that all information presented to medical provider in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment for these conditions.

I hereby acknowledge that I understand that my insurance coverage, including Medicare, may not pay for this non-covered service, and that all services ancillary to this treatment may be also non- covered services and non-reimbursable. I agree to be responsible for payment at the time of service for all services, including non-covered services.