Mobile IM Consent Form

Streamline intramuscular rehydration with our mobile consent form. Easily obtain patient consent for hydration therapy, anytime, anywhere.

Name(Required)
MM slash DD slash YYYY
I hereby grant permission to capture photographs of my likeness by The Struggle Bus for documentation and archival purposes.
I consent to the recording of my image on video by The Struggle Bus for documentation and archival purposes.
I authorize The Struggle Bus to share and use photographs and videos featuring me in their materials for educational and promotional purposes.

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.(Required)
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.(Required)

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.(Required)

Payment

Payment is due prior to service. There has been no representation that this procedure is covered under any insurance plan or that you 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.(Required)
I certify that I am not pregnant.(Required)
I certify that I am not intoxicated on alcohol or any illicit drugs. I authorize and consent to the performance of the procedure(s).

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