I consent to the insertion of a peripheral intravenous catheter and to the infusion of fluids, vitamins, mineral and/or compounded cofactor, and/or medications. I agree and acknowledge that no promises or guarantees were made regarding the efficacy of the infusion. Further, I acknowledge that statements regarding vitamin and mineral infusions have not been evaluated by the FDA and that the infusion of such has no diagnostic value nor is the infusion a substitute, cure, therapy, or treatment for any disease or condition.

I understand that the infusion is being carried out under the direction of Adam Weldzius, NP who is trained in the safe insertion, monitoring, stabilization, and removal of intravenous catheters and infusions. If at any time, a determination is made that the procedure or infusion is outside of the conditions of safety, it may be discontinued.

I understand the benefits of IV infusions may be limited if I am an active smoker, live a sedentary lifestyle, and/or have a diet that contains an excess of calories and/or a deficiency of nutrients. I understand that I may be asked to take oral supplements between treatments and a failure to take these supplements may reduce the benefits of the IV therapy and may even create unwanted effects of the IV therapy. I understand that a series of infusions may be anticipated. I understand that infusion(s) may need to be repeated in the future in order to maintain the benefits.

I acknowledge that I am aware of the risks inherent in peripheral vascular catheterization and infusion that include but are not limited to: local irritation, pain, infection, phlebitis (irritation of the vein), venous thrombosis, shortness of breath, allergic reaction, fluid volume overload, medication interactions, and death. Despite these risks (and others) I consent to the procedure. I may withdraw my consent at any time.

Payment is due at the time of service. There has been no representation that this procedure is covered under my insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless if the infusion cancelled or is stopped at any time prior to completion at the discretion of the technician/nurse/clinical assistant or myself.

I understand that I am responsible for the full cost of the procedure and agree to pay. The procedure(s) and this consent form have been adequately explained to me. I certify that I am not pregnant. If I’m uncertain, I can request a urine pregnancy test at this office. I certify that I am not intoxicated on alcohol or any illicit drugs. I authorize and consent to the performance of the procedure(s

15614 S Harlem Ave, Ste C Orland Park, IL 60462 myhealth@litmedical.net p: 708 866 5900 f: 708 866 5903