IV Therapy Consent Form

INFORMED CONSENT FOR INTRAVENOUS (IV) THERAPY

Kanaklyx LLC

This Informed Consent for Intravenous (IV) Therapy (“Consent Form”) is entered into between Kanaklyx LLC (“Provider”) and the undersigned client (“Client”). This Consent Form establishes the Client’s understanding and authorization for IV therapy as part of their selected plan.

REGULATORY STATUS

  • Some compounds and applications may be considered off-label.
  • Off-label application is for research purposes only and not made for human consumption.

1. TREATMENT INFORMATION

Selected IV Therapy: _______________________________

Primary Objective: _______________________

Frequency and Duration: ____________________________

Anticipated Number of Sessions: __________________

2. PURPOSE AND BENEFITS

IV therapy involves the administration of fluids, nutrients, or other supportive substances directly into a vein. The specific purpose of the recommended IV therapy may include:

  • Hydration and electrolyte support
  • Nutritional supplementation
  • Wellness and recovery support
  • Other: _______________________

3. RISKS AND POTENTIAL SIDE EFFECTS

The Client acknowledges understanding the following potential risks and side effects:

  • Pain, bruising, inflammation, or infection at the insertion site
  • Infiltration (leakage of fluid into surrounding tissue)
  • Phlebitis (inflammation of the vein)
  • Vascular damage or nerve injury
  • Allergic or adverse reactions to administered substances
  • Fluid overload or electrolyte imbalances
  • Nausea, dizziness, or lightheadedness during administration
  • Substance-specific risks as explained by the Provider

4. CLIENT ACKNOWLEDGMENTS

The Client agrees to:

  • Provide a complete and accurate health history.
  • Disclose pregnancy status or possibility of pregnancy.
  • Report any adverse reactions promptly to Kanaklyx.
  • Follow all pre- and post-session instructions.
  • Attend scheduled follow-up appointments.
  • Notify the Provider of any changes in health status or outside therapies.

5. ALTERNATIVES

The Client confirms having been informed of reasonable alternatives to IV therapy, including:

  • Oral hydration and nutrition strategies
  • Transdermal (through the skin) delivery methods
  • Other wellness modalities as recommended

6. COST INFORMATION

  • Estimated cost per treatment: $ _____________________
  • The Client is responsible for payment of services under this plan.

7. VOLUNTARY CONSENT

By signing, the Client confirms that:

  • This Consent Form has been fully explained.
  • All questions have been answered satisfactorily.
  • No guarantees have been made regarding outcomes and results are not guaranteed.
  • Consent is given voluntarily and without coercion.
  • Alternative options have been discussed.

MEDICAL DISCLAIMER

  • All treatments are provided based off of client evaluation.
  • Individual results vary and results are not guaranteed.
  • Always consult your own physician before administering any peptides.
Client Name (Printed)
Client Signature
Date
Kanaklyx Representative Name (Printed)
Kanaklyx Representative Signature
Date