Name *

First Name

Last Name

Phone

(###)

###

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Photography

I hereby grant permission to capture photographs of my likeness by The Struggle Bus for documentation and archival purposes.

I agree

Video Capture

I consent to the recording of my image on video by The Struggle Bus for documentation and archival purposes.

I agree

Promotional Purposes

I authorize The Struggle Bus to share and use photographs and videos featuring me in their materials for educational and promotional purposes.

I agree

Procedure Consent *

I consent to the insertion of a needle into the muscle and injecting vitamins, minerals and amino acids. The procedure involves inserting a needle generally into the muscle of the thigh, shoulder or upper buttocks. IM therapy is a means to deliver vitamins, minerals and other nutrients to the body while avoiding the digestive process.

I agree

Benefits *

If at any time, a determination is made that the procedure is outside of the conditions of safety, it may be discontinued. I understand the benefits of IM Therapy 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 agree

Risks *

I acknowledge that I am aware of the risks inherent in intramuscularly therapy that include but are not limited to: local irritation, pain, infection, injury to the muscle, mild upset stomach, headache, dizziness, or, shortness of breath; allergic reaction, medication interactions, and death. Despite these risks (and others) I consent to the procedure. I may withdraw my consent at any time.

I agree

Payment *

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 agree

Pregnancy *

I certify that I am not pregnant.

I agree