IV Therapy Consent Form

Informed Consent for Intravenous Therapy

This document is intended to serve as confirmation of informed consent for IV therapy and/or chelation as ordered by Michele Lane, DNP, APRN, CNP-F, L3 Aesthetics.

MM slash DD slash YYYY
By signing electronically using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this Agreement (hereafter referred to as your 'E-Signature') is as valid as if you signed this Agreement in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Michele Lane. You are also confirming that you are authorized to enter into this Agreement in your behalf. You understand that a paper copy of this Agreement can also be obtained by contacting Michele Lane at L3Aestheticsinfo@gmail.com or by calling (405) 570-3418