Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Photography

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

I agree

Video

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

I agree

Marketing

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

I agree

IV Consent *

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 agree

Safety *

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 agree

Risks *

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.

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