Intravenous (IV)/Intramuscular (IM) Therapy - Minor Informed Consent

Minor Child Treatment Authorization

I herby declare I am the parent/guardian of the above minor/child and authorize staff of RiverLife Hydration and Wellness  to perform IV/IM nutrient therapy on the minor child listed above. I have been given the opportunity to ask questions about the benefits and risk of IV/IM nutrient therapies, alternative therapies, risks of non-treatment, procedures to be used, and the risks and hazards involved. I believe I have sufficient information to give this informed consent for treatment of my minor child, for whom I am authorized to make this request for treatment. I release RiverLife Hydration and Wellness and all the medical staff from all liabilities for any complications or damages associated with such IV/IM nutrient therapy.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.