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Pure Hydration Informed Consent Form


INFORMED CONSENT to INTRAVENOUS THERAPY and/or INJECTION THERAPY

The following has been explained to me and I understand that:

  1. I will receive the placement of an intravenous (IV) catheter through which I will receive, by my request , IV fluids that are primarily either lactated ringers solution or normal saline solution.
  2. I understand the difference between normal saline and lactated ringers as an IV solution and the risks and benefits of either which I receive.
  3. The IV solution may contain, only by my request, none, one or more than one of the following medications or supplements (vitamins):
  • Vitamin B12 - A nutrient used for boosting mood, energy, concentration, and the immune system; can help with memory loss; may help to slow signs of aging and other ailments.

  • B5 - Dexpanthenol: Helps to maintain healthy metabolism, nerve function, liver function, skin health, eye health, as well as help to boost levels of energy. 

  • B6 - Pyridoxine: helps maintain nerve integrity, skin and red blood cells; Also needed for fat carbohydrate and protein metabolism 

  • Vitamin B Complex (B1, B2, B3, B5, B6, B9) - Responsible for the proper functioning of some of the most important processes of the body’s health processes: cell growth and division, skin health, support for the immune and nervous system, and metabolism.

   * B1 - Thiamine: used in pyruvate and carbohydrate metabolism

   * B2 - Riboflavin: needed for respiratory reactions by catalyzing proteins.

   * B3 - Niacinamide: helps reduce the effects of atherosclerosis,peripheral vascular disease and    hyperlipidemia.

   * B5 - Dexpanthenol: Helps to maintain healthy metabolism, nerve function, liver function.

   * B6 - Pyridoxine: helps maintain nerve integrity, skin and red blood cells; Also needed for fat                                    carbohydrate and protein metabolism.

  • Vitamin C - An essential nutrient used to help boost the immune system, increase energy, and prevent/treat many ailments like the common cold.
  • Zinc - an essential nutrient augmenting the immune system.
  • Glutathione - a very powerful antioxidant that has been used for anti-aging properties and an immune system booster.
  • Taurine - An acid containing amino group organic compound that can aid in central nervous system support and is a powerful antioxidant.
  • Zofran - a prescription medication that can prevent and treat nausea and vomiting.
  • Toradol - this is in the NSAID (Non-Steroidal Anti-inflammatory Drug) family of medications commonly used to for its pain relief and anti-inflammatory effects.
  • Pepcid/Zantac - an antacid commonly used to help indigestion and heartburn.


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  1. I understand the following medical contraindications that exist listed below:
  • Pure Hydration reserves the right to withhold treatment  from clients who have a history of Congestive Heart Failure, Renal Disease, receiving high dose diuretics, previous allergic reaction to any of the informed ingredients.
  • LR is not to be given to clients who have diabetes—these clients will receive normal saline.
  • Toradol will not be given to clients with medical history of a previous stroke, CAD, MI, GI bleeding, bleeding disorders, or ulcers.
  • Zofran is not recommended in patients who are taking SSRI antidepressants or with known prolonged QT syndromes, as this can exacerbate cardiac arrhythmias.
  • Pregnant women are only to receive IV fluids as expressed by our medical director and cleared by their OB/Gyn physician.
  • Multiple missed IV placement attempts are a risk. Pure Hydration reserves the right to withhold treatment after 2 or more attempts to place an IV.


THE RISKS OF IV ACCESS PLACEMENT AND FLUID ADMINISTRATION ARE AS FOLLOWS:

THE RISKS OF IV ACCESS PLACEMENT AND FLUID ADMINISTRATION ARE AS FOLLOWS:

- Infections to the overlying skin, deep tissues, and systemically (i.e. blood stream)—with the accompanying risks of infections to other organs and/or organ systems of the body, such as endocarditis, venous or arterial injury, hematomas, compartment syndrome of the extremity, loss of perfusion and possibility of limb loss, phlebitis, or thrombosis with accompanying emboli formation. Risks also include fluid overload, pulmonary edema, pulmonary embolism, complex regional pain syndrome, allergic reaction to the fluids and/or medications and vitamins, local nerve damage, pain or damage to internal organs such as the kidneys, brain or liver, cardiac arrest, and death. Local bruising is the most common visible risk of this procedure. These risks may be related to IV placements and IV fluid administration with or without the included vitamins and/or medicines administered by your request.

THE RISKS AND BENEFITS OF EACH MEDICATION ABOVE THAT I HAVE REQUESTED TO BE INCLUDED IN MY IV SOLUTION HAVE BEEN EXPLAINED TO ME TO MY SATISFACTION AND THE LITERATURE EXPLAINING THESE TOPICS HAS BEEN MADE AVAILABLE ON MY REQUEST.  I ALSO UNDERSTAND THAT ALL MEDICATIONS HAVE SIDE EFFECTS AND THAT ADMINISTRATION THROUGH AN IV ALSO HAS RISKS OF ADVERSE REACTIONS AND CONSEQUENCES INCLUDING ALLERGIC REACTION, ANAPHYLAXIS, NAUSEA, FEELING ILL AND LIGHT HEADEDNESS. I HAVE RECEIVED AND UNDERSTAND THE INFORMATION REGARDING THE POTENTIAL SIDE EFFECTS AND RISKS OF RECEIVING ALL OF THE REQUESTED MEDICATIONS LISTED ABOVE IN CONJUNCTION WITH THE IV FLUIDS ADMINISTERED.


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Alternatives to having an IV access site placed and the administration of IV fluids and the vitamins and medications requested are:

  1. Oral hydration or fluid intake of water and or electrolyte infused beverages (provided here at Pure Hydration).
  2. Oral intake of medications which are the same or similar to what you have requested and similar to over the counter preparations.
  3. I understand that unless I have come with a physician’s order or request for the services of Pure Hydration, I am not under the care of a physician or medical director at Pure Hydration, but have chosen to undergo IV access rehydration by my own choice and without medical recommendations from Pure Hydration, its medical director, or its employees.
  4. I understand that the personnel and professionals at Pure Hydration rely on my pre-treatment history and that providing an accurate and complete history of my medical conditions is essential to my safety. I understand that any inaccurate statements or falsified answers regarding my medical history, uses of drugs or medications or prior medical conditions may lead to an inappropriate or dangerous application of IV fluids and/or medications that you may request. All changes or updates in medical history on subsequent visits must be disclosed to the provider at each visit.
  5. I understand that in the course of treatment at Pure Hydration, the procedure may have to be interrupted and that further medical care may be necessary on site or require transport to an Emergency Department or urgent care center which cost will not be covered by Pure Hydration or any of its employees, owners or medical directors.


Pure Hydration does not offer diagnostic services. Our medical guidelines are stringent and specific based on the best interests of our clients. Pure Hydration does not, in any circumstance, condone, encourage, or recommend excessive alcohol consumption. Excessive alcohol consumption is detrimental to one’s health and wellness.

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BY SIGNING THIS FORM, I AGREE THAT I HAVE EITHER READ OR HAD THIS FORM READ TO ME AND/OR EXPLAINED TO ME AND THAT I COMPLETELY UNDERSTAND THE CONTENTS THAT WITHIN IT. I HAVE ALSO HAD ADEQUATE TIME TO ASK QUESTIONS AND RECIEVE ANSWERS TO ANY AND ALL QUESTIONS THAT I MAY HAVE REGARDING THIS PROCEDURE. I ALSO AGREE THAT I MAY HAVE RECEIVED ADDITIONAL INFORMATION INCLUDING, BUT NOT LIMITED TO ANY OF THE MATERIALS LISTED IN THIS DOCUMENT AND RELATED TO THE PROCEDURE WITHIN THE PROVIDED DOCUMENTS.

TO MY KNOWLEDGE I AM NOT PREGNANT OR SUSPECT TO BE PREGNANT AT THE TIME OF THIS TREATMENT OR PROCEDURE. TO MY KNOWLEDGE I AM NOT NURSING AT THE TIME OF THIS TREATMENT OR PROCEDURE. I HAVE CLEARLY VOICED THIS INFORMATION TO THE PROVIDER AT PURE HYDRATION.  I AM AWARE OF THE POSSIBLE DANGERS ASSOCIATED WITH SOME OF THE MEDICATIONS PROVIDED BY PURE HYDRATION AND CONSENT TO TREATMENT.


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ARBITRATION: In the event of any litigation arising out of or relating to the rendition of services by PURE Hydration LLC, or any of its agents or employees (collectively, the “Provider”), this Agreement, or any breach of any duty or obligation arising out of or relating thereto, Patient irrevocably and knowingly agrees to submit all matters to resolution by arbitration in accordance with the commercial arbitration rules of the American Arbitration Association (AAA). All parties expressly waive any challenge to the use of arbitration in accordance with this paragraph. The arbitration shall take place in Duval County, Florida. The arbitrator shall have no jurisdiction to award punitive damages or attorney’s fees. The parties hereto agree that jurisdiction and venue of the entry of judgement of the arbitrator shall be in Duval County, Florida. The arbitrator is directed to award the expenses of the arbitration, including required travel and other expenses of the arbitrator and the costs and charges of the American Arbitration Association to the prevailing party in the arbitration. Each party hereto hereby knowingly, voluntarily and intentionally elects arbitration and thereby waives the right to a trial by jury with respect to any controversy or claim based, directly, or indirectly, hereon, or arising out of, under or in connection with the transactions contemplated by this Agreement and any course of conduct, course of dealing, statements (whether verbal or written) or actions of the parties hereto. This provision is a material inducement for the Provider to enter into this Agreement.

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By signing I have answered all questions truthfully and fully understand and agree to conditions of Pure Hydration.   

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