Consent Form for Perfecting Myer’s Cocktail Drip

Please sign below

Consent - PMC
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 understand that the infusion is being carried out under the direction of General Physician Tanya Marie Cabais and by a licensed nurse who is trained in the safe insertion, monitoring, stabilization, and removal of intravenous catheters and infusions. 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 understand that a series of infusions may be anticipated. I understand that infusion(s) may need to be repeated in the future in order to maintain the benefits.

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.


Payment is due before the service can be administered. There has been no representation that this procedure is covered under my insurance plan or that I 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.

I certify that I am not pregnant. I can provide a laboratory test result if needed. If I am uncertain, I am aware that I can request Juan Medical to conduct a urine pregnancy test (send a request at on a separate appointment before the IV drip is administered.

I certify that I am not intoxicated on alcohol or any illicit drugs.

I authorize and consent to the performance of the procedure(s).

I hereby declare that I have read and understood what is stated here, and that I fully understand the risks and benefits of the IV drip service since they were shared in a language that I can understand.

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