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.
Ozone (O3) is a gas formed by running an electric current through oxygen. Ozone will react with proteins and fats to form chemical compounds called ozonides, which react within the body to cause increased oxygen utilization and immune function.
Prolozone involves injecting a solution of procaine, saline, sodium bicarbonate, glucose, steroid and B vitamins, prior to the injection of ozone gas.
_____ Possible side effects include mild nausea, vomiting, dizziness, blurred vision, headache, trouble speaking or somnolence.
_____ Rare complications include cardiovascular stimulation and liver toxicity.
_____ 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 will conform and comply with the recommended dosing of ozone. If recommended, I will obtain baseline and periodic lab tests to assure proper monitoring of my ozone.
_____ 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.
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 ozone or prolozone prescribed.
Patient / Legal Guardian Signature / Date:
Nurse/Medical Assistant/Physician / Date:
