IV THERAPY CONSENT
Drip Therapy Mobile IV infusion is a safe and effective method of supplying the body with natural vitamins, minerals, and amino acids directly into the bloodstream.
PROCEDURE
Intravenous(IV) infusion of fluids is done through a needle/catheter. The Drip Therapy Mobile IV drips that are used are exactly the same quality as those used in a hospital setting. Most of our infusions take 30-45 minutes.
INTRAVENOUS(IV) INFUSION CONSENT FORM
This document is consent for your IV infusion as ordered by the Drip Therapy Mobile IV physician and/or nurse. I have informed the nurse and/or physician of any known allergies to medications or other substances. I have informed the nurse and/or physician of all current medications and supplements.
I have fully informed the nurse and/or physician of any medical or surgical history. IV infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration(FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease.
These IV infusions are not a substitute for your physician’s medical care.
I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits.
I understand that: 1. The procedure involves inserting a needle into the vein and injecting the solution. 2. Alternatives to IV therapy are oral supplements, intramuscular supplements or dietary and lifestyle changes. 3. Risks of IV therapy include but not limited to a) Occasionally: discomfort, bruising, and pain at the injection site. b) Rarely: inflammation of the vein used for the injection, phlebitis, metabolic disturbances, and injury. c) Extremely rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death. 4. Benefits of IV therapy include a) Injectables are not affected by stomach or intestinal absorption problems. b) Total amount of infusion is available to the tissues c)Higher doses of nutrients can be given without intestinal irritation.
I am aware that other unforeseen complications could occur. I do not expect the nurse(s) and/or physician to anticipate and explain all risk and possible complications. I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered.
I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV infusion therapy, including any other procedure that may be indicated.
My signature below confirms that: 1. I understand the information provided on this form and agree to all statements above. 2. IV therapy has been adequately explained to me by my nurse. 3. I authorize and consent to the performance of IV therapy. 4. I release The Drip Therapy Mobile IV and Dr. Shust and all the medical staff from all liabilities for any complications or damages associated with my IV therapy.
IV Therapy Consent Form 1) You have the right to be informed of the procedure and the risks and benefits. Procedures are not performed until you have had an opportunity to receive information and give consent. The procedure involves inserting a needle into your vein or muscle to inject the formula.
1. Absolute contraindications: liver failure, renal failure, Addisons Disease, Congestive Heart Failure
2. Relative contraindications: Thalassemia, G6PD deficiency, decreased renal function, drug nutrient interactions, allergy and/or sensitivity to any substances used.
3. Caution: HIV/AIDS, immune suppression, post splenectomy, recent burns, malnourishment, chemotherapy.
The procedure will be performed under the direction of Dr. Shust.
Your signature below indicates
1. You understand the information provided on this form and agree to the foregoing.
2. The procedure has been adequately explained.
3. You have received all the information and explanation you desire concerning the procedure.
4. You authorize and consent to the procedure.
5. None of the above conditions exist in your health history.