PT-141 Peptide (nasal)

Informed Consent Advanced Mobile IV

I give consent to Advanced Mobile IV to administer vitamins, minerals, medications, and other nutrients via injection and/or intravenously. I understand that intravenous nutrient therapy is not approved or accepted for the purpose(s) of treatment or prevention of disease. I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, exercise, and proper diet). I have informed Advanced Mobile IV of all of my current medications and supplements that I am taking as well as any health problems and allergies. As with any other medical procedure, a small percentage of clients do not respond to this therapy. I have been informed of possible risks and side effects including but not limited to discomfort and bruising at the injection site, infection, bleeding, thrombophlebitis, fatigue, congestive heart failure, metabolic disturbances, anaphylaxis, cardiac arrest, or death. I understand the nature of the proposed therapy and the risks involved have been explained to my full satisfaction. Benefits of intravenous therapy include nutrients bypassing the stomach and not being disturbed by intestinal absorption. This process allows nutrients to be available to the tissues by means of a high concentration gradient. I understand that this treatment is voluntary and I may terminate it at any time. I acknowledge that Advanced Mobile IV is self-pay only, and does not accept Medicare, Medicaid, or any other private insurance. I am responsible for full payment at the time of service or otherwise agreed by previous arrangements between myself and Advanced Mobile IV. I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations, and materials that may be provided to me for education. I acknowledge that I have had the opportunity to ask questions, and all of my questions have been answered to my full satisfaction. My agreement will constitute a full and final release of any legal responsibility of Advanced Mobile IV and all associated before, during, and following my treatment, and in my case and/or any other medical treatments that may be necessary as a result thereof. My agreement confirms that I am 18 years of age or older, and of sound mind. I have read, understood, and agree to this consent, and to receive treatment. All of my questions have been answered to my full satisfaction.

PURPOSE

The purpose of this form is to obtain your consent for: Health and wellness services administered by Advanced Mobile IV and its affiliates. These services are being provided by: Advanced Mobile IV and its affiliates. The reason these services are being provided is: General Health and Wellness.

NATURE OF THE SERVICES

The Drip IV Therapy services consist of infusions into my body through IV drip or IM injection, of minerals, vitamins, and/or other nutrients suspended in a liquid form. A needle and or a needle and a catheter will be inserted through my skin either into a muscle or a vein in order to introduce this liquid into my body.

WEIGHT LOSS

I understand that my program may consist of a balanced-deficit diet, a regular exercise program, instruction on behavior modification techniques, and may involve the use of anti-obesity medications. I further understand that if medications are used, they have been used safely and successfully in private medical practices with experienced obesity medicine specialists as well as in academic centers for periods exceeding those recommended in the product literature. I understand that much of the success of the program will depend on my efforts and that there are no guarantees that the program will be successful.

RISKS, BENEFITS AND ALTERNATIVES

The benefits of the Services include potentially: increased energy, hydration, increase in metabolism, cardiovascular support, nail, skin and hair health, and immune-system support. The risks include: (i) injection/venipuncture site swelling, redness, irritation, bruising, bleeding, and infection, (ii) reaction to vitamins including fever, aches, nausea, rash, hives, wheezing, joint swelling, and general allergic reaction, and (iii) other minor complications of IV or IM injection.

NON-FDA EVALUATED OR APPROVED

I, as patient signing and consenting below, understand and acknowledge that the United States Food and Drug Administration has not evaluated or approved the treatments I am about to receive to diagnose, treat, cure, or prevent any disease. The FDA might in fact recommend other treatments.

JUDGMENT AND CHANCE TO ASK QUESTIONS

In giving the consent hereunder, I, as patient, am relying on the judgment of the clinical professional evaluating me and administering the treatments. I have had the meaningful chance to ask questions and have received satisfactory answers to my questions. The risks and potential benefits of the treatment I am consenting to have been explained to me. Alternatives to the treatments I am consenting to have also been discussed with me.

MEDIA RELEASE

I hereby grant permission to Advanced Mobile IV to use photographs and/or videos obtained from me for advertising purposes.

CONSENT

In considering all of the factors above, including risks, benefits and potential adverse results and reactions, and based on my conversations with my clinical professional about the same and alternative therapies, I hereby consent to examination, treatment, and IV therapies as listed above, including the placement of IV catheters or IM injections into and through my skin and/or veins and muscles by our medical director or the clinical professionals working under his direction.

I understand that some treatments may include peptides, including growth hormone-releasing hormones and Research Use Only peptides. Some peptides may not be FDA-approved and are intended for research or investigational purposes. I consent to their use and understand these treatments' risks and experimental nature. I accept full responsibility for any adverse effects and release Advanced Mobile IV from liability related to the use of peptides.

I understand that some services may fall under the alternative or integrative medicine category, which may include homeopathic remedies, naturopathic treatments, and nutraceuticals. These therapies are not part of conventional medical standards and may not have undergone rigorous scientific evaluation. I consent to receive such treatments as part of my wellness care.

I understand that some substances used in my care, including vitamins, amino acids, hormones, or medications, may be used “off-label,” meaning the use is not officially approved by the FDA. I acknowledge and accept the off-label use of these substances as part of my treatment.

My treatment may involve nutraceuticals, which include combinations of vitamins, amino acids, peptides, and other compounds to support health and wellness. I understand that these therapies are commonly used in alternative medicine but may not be FDA-evaluated or approved.