Fill out the form below to consent to IV Therapy.

IV Infusion and Injection Consent Form

IV Infusion and Injection Consent Form 

This form outlines that you understand that a peripheral intravenous catheter will be inserted into a vein in your body, and you will have fluids, vitamins, minerals, nutrient, and/or medications infused directly into your body. This is considered “IV Infusion Therapy.” If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.”

Please check each box below acknowledging that:


Voluntary Nature of Treatment and Alternative Therapies 

Treatment with IV and injectable vitamins/hydration/nutritional/mineral and/or medications offered at What The Health Works is completely voluntary in nature. Alternative therapy for the symptoms you are seeking IV infusion and injectable therapy for include, not are not limited to, ongoing treatment by your primary care provider and/or specialty provider, oral supplementation, and dietary/lifestyle modifications.

I acknowledge that IV infusion and injection therapy provided at What The Health Works is voluntary in nature and that I am seeking out this therapy on my own or from the recommendation of my referring provider. I acknowledge that I have also notified my medical and/or mental health provider about my decision to undergo IV and injectable vitamin/hydration/nutritional/mineral therapy. I acknowledge the alternative treatment options and have voluntarily decided to pursue IV and injectable therapy.

Final patient consent for treatment. 

  • I have had the nature of the procedure and/or treatment, the benefits of treatment, the risks of treatment, the side effects, the alternative therapies for my medical condition or symptoms I am seeking treatment for, and the chances of treatment success explained to me. I have had all my questions and concerns answered to my satisfaction. I acknowledge that I have been given sufficient information about IV hydration/vitamin/mineral/nutrient infusion and injection therapy and all its associated risks and benefits upon which to make an informed decision about treatment.
  • I acknowledge that there are no guarantees regarding the results of treatment and its effect on my presenting condition.
  • I give my consent for the use of emergency intervention if required during treatment.
  • I certify that I am of sound mind and body to make medical decisions and to consent for treatment.
  • I certify I will continue to remain under the care a licensed and qualified primary care provider and/or mental health provider as IV infusion and injection therapy is considered an adjunctive and non-medically necessary treatment option, not a complete one.
  • I release Dannette Fritzlan and Dr. Authumn Lewis at What The Health Works and all the medical staff from all liabilities for any complications or damages associated with IV infusion and injection therapy.
  • I have read this consent and fully understand the information within it and I voluntarily authorize and consent to the treatment options, including but not limited to IV infusion therapy, provided to me at What The Health Works.

Or download the form and bring it with you to your appointment.

Download the IV Therapy Consent to Treatment form.