I, , being the
parent/guardian of , a minor child, authorize
The Scarlet Drip to perform IV/IM nutrient therapy on .
I have been given the opportunity to ask questions about the benefits and risks of IV/IM nutrient therapies, alternative therapies, risks of non-treatment, procedures to be used, and the risks and hazards involved.

I believe I have sufficient information to give this informed consent for treatment of my minor child, for whom I am authorized to make this request for treatment. I release
The Scarlet Drip and all the medical staff from all liabilities for any complications or damages associated with such IV/IM nutrient therapy.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

Guardian Signature (Full Name):

Date: