VITA VERA LLC
Patient Consent Form

To the patient. The purpose of this document is to make you aware of the nature of the procedure to be performed by Vita Vera LLC (“Vita Vera”) and the related risks so that you can decide whether or not to
proceed with the treatment.

What is Intravenous Nutrition Therapy?

IV nutritional therapy, or Intravenous (IV) Supplementation, is
a procedure by which vitamins, minerals, amino acids, and other nutrients are slowly administered via a small needle into the patient's vein. The possible benefits of IV Supplementation include: injectable
nutrients are not affected by stomach, intestinal disease, or malabsorption; the total amount of the infusion is absorbed and available to the tissues; nutrients are forced into cells by means of a high concentration gradient; and higher doses of nutrients can be given than are possible by mouth without intestinal irritation
.
No Medical Diagnosis or Treatment.

Prior to your treatment, you will fill out a patient questionnaire that
helps the health care professional understand your overall health. However, Vita Vera will not diagnose, treat, or cure any specific disease, and the nutritional recommendations Vita Vera makes do not constitute treatment for any disease or affliction. Vita Vera will not recommend any medicinal treatment(s).

Limitations.

An initial series of treatments is recommended, and these treatments may extend over a number of weeks or months. The benefits of intravenous nutrient therapy are much greater if you follow a healthy lifestyle (non-smoking, weight control, proper exercise, proper diet and nutritional supplementation). As with any other medical procedure, you may not receive any benefit because they do not occur predictably with every patient and in some percentage of patients, they may not occur at all. No comment or recommendation should be construed as inferring or implying a medical diagnosis. Since every human being is unique, Vita Vera cannot guarantee any specific result from Intravenous Supplementation. Medication and/or medical conditions may have a negative impact on the positive effects of IV Supplementation.

Health Concerns.

If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your General Practitioner or consulting medical provider. If you are under the care of another healthcare provider, it is important that you inform your other healthcare providers of your use of nutritional supplements. Nutritional therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program.

Risks and Complications.

• As with anything we put in our bodies, medications, drugs and nutritional supplements may exhibit some side effects in certain individuals. Adverse effects from Intravenous Nutrition Therapy include but are not limited to:
• Discomfort, bruising, and pain at the site of injection;
• Inflammation, infiltration, irritation, or infection at the site of injection;
• Phlebitis (irritation of the vein)
• Venous thrombosis;
• A potential to feel a warming sensation throughout your body, which is a normal feeling when
  magnesium is used in your treatment. If however you are in any discomfort or distress, please tell the health care professional immediately.
• Possible fall in blood pressure, which can be related to magnesium in the IV. The health care provider will be present and able to help you by stopping the infusion and/or providing some extra IV fluids to bring the blood pressure to normal.
• Allergic reaction or anaphylaxis to a nutrient, a needle, or other supplies used.
• There is a potential for dizziness, feeling faint, or changes in blood pressure and blood sugar during or following your treatment due to some nutrients. Inform the doctor immediately if you feel any of these symptoms.
• Other rare, but possible side effects include: fever, nausea, oedema, upset stomach, difficulty breathing, arrhythmia and stroke.
• As with any treatment there is also a possibility of other unforeseen adverse effects

If you are using medications of any kind, you are required to alert Vita Vera and its health care provider to such use, as well as to discuss any potential interactions between medications and nutritional products with your pharmacist. If you have any physical or emotional reaction to IV Supplementation, discontinue use immediately, and contact your practitioner to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the supplementation.

Alternatives.

This is strictly a voluntary procedure, provided only with your express consent. No treatment is necessary or required. Other alternative treatments, which vary in sensitivity, effects and duration, include oral supplementation and/or dietary and lifestyle changes.

CONSENT TO PROCEDURE:

I certify that I have read and fully understood this document and the risks, benefits, and alternatives to this procedure described above. I have had sufficient opportunity for discussion and to ask questions. I have had time to consider the procedure.

I understand that the nature and purpose of this procedure may be considered medically unnecessary, has not been proven by scientific testing and peer-reviewed publications and is not currently an indicated treatment. I acknowledge this infusion is fully voluntary and I give permission for Vita Vera to provide this procedure.

I understand that the procedure involves inserting a needle into a vein and injecting the selected IV Supplementation protocol. I understand that the infusion is being carried out under the direction of Dr. Jeffrey Starre, MD and by a nonphysician 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 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 the benefits of IV Supplementation may be limited if I am an active smoker, live a sedentary lifestyle, use illicit drugs, consume excessive alcohol, and/or have a diet that contains an excess of calories
and/or a deficiency of nutrients.

I believe that I have adequate knowledge to request this procedure and consent to the proposed procedure. I accept the risks and complications associated with the procedure and there are no material
circumstances preventing me from having this procedure.

I have provided an accurate past and present medical history, and I have not withheld any information. I certify that I am not intoxicated on alcohol or any illicit drugs.

I understand the alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.

I understand that several IV Supplementation sessions may be required to address any vitamin deficiencies. I further understand that I may be asked to take oral supplements between treatments and a failure to take these supplements may reduce the benefits of the IV Supplementation and may even create unwanted effects of the IV Supplementation.

I am aware that other unforeseeable complications could occur. I do not expect Vita Vera to anticipate and or explain all risks and possible complications. I rely on them to exercise clinical judgment during the
course of therapy with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that at any stage during the infusion/injection, I have the right to request that the procedure is terminated, however I accept that I will not be reimbursed once the IV or IM procedure or supplementation has commenced.

Consent to Cost/Payment. I am aware of the cost of the procedure and that full payment is expected at the time of service. I am also aware that no procedure fees can be refunded in the case of a sub-optimal
result or complication as all fees paid are entirely in respect of the service provided; i.e. professional time, expertise, product costs and other costs incurred by the healthcare provider in providing the procedure and such costs are incurred independently of the results achieved. Additional costs may occur should complications arise from the procedure.

By signing below, I hereby authorize and give my full consent to receive an INTRAVENOUS SUPPLEMENTATION protocol from Vita Vera LLC.