Please read this form entirely. It contains information to assist you in making a decision to have a specific therapy. Initial each paragraph if you understand it. If you do not understand it, do not initial it and each paragraph will be discussed with you separately. There are risks and complications that may result from this therapy, they are rare, but do exist and you must be aware of them.
The intravenous (IV) procedure involves inserting a needle into your vein and infusing prescribed nutrients (vitamins, minerals, amino acids), medications or chelation agents.
_____ While the value of IV therapy has been noted in scientific monographs, its value is not expressly recognized by the United States Food and Drug Administration (FDA) and its use in medical treatment and is considered nonstandard treatment by the medical community with the exception of some physicians who practice integrative, functional or nutritional medicine.
_____ Potential side effects include discomfort, bruising, pain at the site of injection, inflammation of the vein used for injection, metabolic disturbances, minor allergic reactions such as itchy eyes or nasal congestion, headache and injury.
____ Rare complications include racing heart, fainting, shortness of breath, severe allergic reaction, kidney or liver damage, breakdown of red blood cells, anaphylaxis, cardiac arrest, or death.
_____ The above listed risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization and/or extended outpatient therapy to permit adequate treatment.
_____ I understand that IV therapy may not currently be medically accepted for treating certain conditions and may not be FDA‐approved. I am aware and understand the currently “standard” medically‐indicated treatment for my condition.
_____ I understand and accept that because this procedure may be considered “medically unnecessary” or “experimental”, it may not mitigate, alleviate, or cure condition(s). The possible benefits may not be apparent immediately.
_____I understand that medicine is not an exact science and that no guarantees are offered regarding my expected results. I am aware that it is possible that this treatment will not work for me.
_____ In addition to discussing other modes of therapy that may be used for the treatment of my condition, my provider and I have discussed and I understand the possibility of a referral to a specialist in my condition(s) if I have not already consulted with an appropriate specialist.
I have read the foregoing information, it has been explained, and I understand it. All of my questions have been answered. By executing this form, I am indicating that I have no questions whatsoever and I give my full informed consent to have Intravenous Therapy performed. I further agree to follow all post-treatment instructions.
Patient / Legal Guardian Signature /Date:
Nurse/Physician / Date:
