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High Dose Vitamin C Therapy Consent Form

1. I agree to an intravenous administration of Vitamin C. The dose can reange from 10 to 100 grams.

2. I understand that vitamin therapy will be performed under the direction of my Registered Nurse and/ or Physician.

3. I understand that High Dosage Vitamin C Therapy is a controversial procedure at the present time and that no guarantee can be made for this form of therapy. I am aware of possible toxic side effects from this procedure such as discomfort, muscle cramps, vomiting, hot/cold flashes, kidney problems and infrequent fatal complications. This is an alternative form of therapy. I have been informed that high blood levels of Vitamin C can cause a falsely high reading on finger stick blood sugars. Glucometer readings cannot be relied upon for at least 6 hours after the completion of intravenous Vitamin C. Standard serum glucose testing is unaffected and can be used during or following the IV Vitamin C infusion.

My signature below confirms that:

1. I understand the information provided on this form and agree to the all statements made above.
2. High Dosage Vitamin C IV Therapy has been adequately explained to me by my nurse and/or physician.
3. I have received all the information and explanation I desire concerning the procedure.
4. I authorize and consent to the performance of High Dosage Vitamin C IV Therapy.
5. I release MI AMAUR AESTHETICS, and all the medical staff from all liabilities for any complications or damages associated with my High Dosage Vitamin C IV Therapy.

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