I give full permission to Checkmate Health Strategies to source my licensed medical provider for IV therapy. I understand that the medical personnel may not be employees of Checkmate Health Strategies, and are rather 3rd party contractors and/or affiliates. I authorize and consent to IV Therapeutics/IM Injectables being administered by the EMT, RN, NP, PA, CRNA, DO, or MD that is affiliated with Checkmate Health Strategies. I have requested this vitamin and mineral therapy. I have been counseled on all risks, benefits, and possible adverse effects of IV treatments.
I have been informed of the possible risks and side effects including but not limited to discomfort at the injection site, thrombophlebitis, fatigue, allergic reaction, congestive heart failure, lowering of blood sugar levels,fever, chills, and generalized complaints. I understand that this therapy should not be used if I am pregnant unless I have a severe life threatening disease.
I acknowledge that I have had the opportunity to ask questions and with respect to my proposed therapy and treatments to be utilized and all my questions have been answered to my full satisfaction.
My signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of intravenous therapy and/or intramuscualr injection in my case and/or any other medical treatments that may be necessary as a result thereof.