VitaShots IV Therapy Client Form

IV THERAPY

Leah Ralston RN
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How soon are you wanting to get an IV?
Choose a pre mixed IV Cocktail Below or build your own.
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Start Here and Choose your BASE IV

Cocktail Add Ons (requires Wellness IV Base)

Single Add Ons (requires Wellness Base or Saline Base)

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Start Here and Choose your BASE IV

Saline Only Base - Build Your Own IV$100.00
Get hydrated and replenish fluids with saline and build your own IV cocktail by choosing the add-ons you want below.

WELLNESS IV - COCKTAIL BASE - Saline Required$100.00
WELLNESS IV Vitamin C, Vitamin B6, B Complex, Calcium, Magnesium

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Item subtotal:$0.00

Cocktail Add Ons (requires Wellness IV Base)

IV ADDON IMMUNITY BOOSTER$150.00
IMMUNITY IV Wellness IV plus Glutathione, Zinc and Taurine

IV ADDON REBOOT$100.00
REBOOT IV providing replenishing fluid, electrolytes, vitamins and antioxidants to help the body rebuild and rid itself of unwanted toxins. Hydrate, energize and release those unwanted toxinsWeakened immune system, allergies, muscle aches, stress, depression, headaches, difficulty in concentrating, poor food and nutrition choices, low metabolism and energy, fine lines and wrinkles, formation of acne and much more.Indication:Weakened immune system, allergies, muscle aches, stress, depression, headaches, difficulty in concentrating, poor food and nutrition choices, low metabolism and energy, fine lines and wrinkles, formation of acne and much more. Wellness IV plus Gluta, Glycine, B12, Magnesium, Trace Mineral & Zofran (optional)

IV ADDON - RECOVERY - Pain Migraine$125.00
IV Pain/ Migraine Add-on provides replenishing fluids, vitamins, minerals and amino acids at a cellular level reducing inflammation while increasing circulation.

Single Add Ons (requires Wellness Base or Saline Base)

VITAMIN C - ASBORBIC ACID$80.00
Vitamin C ia a powerful anti oxidant providing replenishing fluids, vitamins, minerals and amino acids to boost the body's immune system.A deficiency of vitamin C broadly affects the various key aspects of immune function, which include the innate system we are born with, the adaptive system that develops from infancy to young adulthood, the cells that kill invaders, the cells that coordinate those attacks, and even the production of antibodies that fight known infections. Stress is another major trigger for reducing vitamin C levels, leaving the affected individuals vulnerable to infection at precisely the time that stronger immune support is needed.Indication:Cold and flu symptoms, seasonal allergies, reduce oxidative stress, protect against free radicals, boost immune system and much more.

ZINC$25.00
Zinc, a nutrient found throughout your body, helps your immune system and metabolism function. Zinc is also important to wound healing and your sense of taste and smell.

Calcium$50.00
Supports Bone Structure and function, regulates how muscles and blood vessels contract and dilate.

Magnesium$50.00
Energy Boost. Relaxes muscles, aids in sleep, helps lower blood pressure, relieves anxiety, keeps your bones strong, improves heart health.

Trace Minerals$60.00
Contains: Zinc, Manganese, Selenium & Copper.

Tri-Amino Acids$60.00
Contains: Argnine, Citrylline & Ornithine

B12$30.00
Helps Maintain Energy Levels. Prevents Memory Loss Better Mood & Mental Clarity Deeper Sleep Boost Metabolism Balances Immune System

B-Complex$30.00
Vitamin B-Complex is essential for a wide variety of functions in the human body. When taking the b-Complex you will see benefits which include:More Energy, Helps avoid type 2 diabetes, maintain healthy blood cells, proper functioning or nervous and digestive system. Provides healthy skin, hair & nails. Helps to avoid neurodegenerative diseases like Alzheimer's disease. Helps avoid several cardiovascular.

Vitamin B6$30.00
Protects against heart and kidney disease. Helps nervous system function, immune booster, maintains healthy levels of hormones in body. Helps improves metabolism, helps treat eczema, dandruff, acne, hair loss & dry skin.

Glutathione$60.00
Primary Function is to serve as an antioxidant within the body to help protect against damage by UV light, Air pollution, heavy metals, and other potentially harmful substances. The world's most powerful antioxidant, detoxifies, strengthens the immune system, reduce cellular inflammation, and protects against oxidative stress

Glycine$60.00
Preventing Sacapenia (Muscle wasting or deterioration) Improving sleep quality, improving mental performance and memory. Protects skins from signs of aging. Protecting collagen in joints and reducing joint pain. Boosting energy levels & stabilizing blood sugars.

Taurine $60.00
Better Physical Function Improves Heart Health Reduce Inflammation Lowers Blood Pressure Calms Nervous System Improves Heart Function Lowers Cholesterol Improves Insulin Resistance Prevent Obesity

Total $0.00
Informed Consent for Intravenous (IV) Therapy performed by VitaShots Mobile

VitaShots Mobile is an innovative vitamin shot and IV therapy clinic that takes an advanced approach to wellness. VitaShots Mobile is dedicated to helping patients achieve and maintain optimal health. The team of highly qualified nurses and medical assistants at VitaShots Mobile provide a comprehensive menu of services including IV therapy, quick and easy vitamin boosts, and effective weight loss support.

Products and Services

We are providing IV and injection vitamin boosts. Vitamins and minerals are essential for the cells to function properly. Vitamin boosts and infusions are the fastest, most efficient way for your body to receive hydration and micronutrients. These essential nutrients are delivered in to the bloodstream where your cells can begin to uptake what your body needs right away.
This document is intended to serve as confirmation of informed consent for IV therapy and boost

___(Initials) I have informed the physician of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics.

___(Initials) I have informed the doctor of all current medications and supplements.

I understand that I have the right to be informed during the procedure, 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.

The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time,
prescribed nutrients (vitamins, minerals, amino acids).
I understand that risks, benefits and alternatives to IVs may include but are not limited to:
1. The Risks and potential side effects
o Discomfort, bruising, and pain at the site of injection.
o Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. o Severe reaction, anaphylaxis, cardiac arrest, or death.
2. The Benefits
o Injectables are not affected by stomach or intestinal disease.
o Total amount of infusion enters the bloodstream and ia available to the tissues
o Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can

accompany doses given by mouth.
o IV chelation therapy helps to reduce and eliminate heavy metals.
3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes. 4. I am aware that other unforeseeable complications could occur. 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.
5. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated. 6. I understand the information provided on this form and agree to the foregoing. I understand that there is no
implied or stated guarantee of success or effectiveness of any treatment. The procedures) set forth above has been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials.
My signature below confirms that:
1. I have received all the information and explanation I desire concerning the procedure. 2. I authorize and consent to the performance of the procedure(s)
Please answer these health questions to ensure you can take all supplements

If you answer YES to any of these questions we recommend you speaking to your primary care provider before adding IV Therapy.
Do you have known sensitivity to cobalt or Early Leber’s Disease ( hereditary optic nerve atrophy)?*

YesNo
Do you have know Urine Maple Disease?*

YesNo
Do you have ALS or Lou Gehrig’s Disease?*

YesNo
Are you pregnant or post-partum (< 6 weeks)?*

YesNo
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?*

YesNo
By signing below, I have read the information provided regarding the requested injection, and I have had a chance to ask questions. I understand all the benefits and risks and request that the injection to be given to myself or to the person named for whom I am authorized to make this request. I will not hold my workplace, VitaShots Mobile LLC, or the Medical Director Dr Maxine Thomas MD responsible and I assume full responsibility for any reactions that may result.
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IV THERAPY

Choose a pre mixed IV Cocktail Below or build your own.

Please answer these health questions to ensure you can take all supplements