AWE - Informed Consent for Intravenous (IV) Therapy
Please correct the errors described below.
Phone: +1 (480) 603-6895
This document is intended to serve as confirmation of informed consent for IV infusion therapy.
I understand that I have the right to be informed during the procedure, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.
The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids).
1. The Risks and potential side effects
- Discomfort, bruising, and pain at the site of injection.
- Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
- Severe reaction, anaphylaxis, cardiac arrest, or death.
2. The Benefits
- Injectables are not affected by stomach or intestinal disease.
- Total amount of infusion enters the bloodstream and ia available to the tissues
- Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth.
- IV chelation therapy helps to reduce and eliminate heavy metals.
3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes.
4. I am aware that other unforeseeable complications could occur. I understand the risks and benefits of the procedure and have had the opportunity to have all of 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.
5. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
6. I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures) set forth above has been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials.
Your information will be encrypted.
Phone: +1 (480) 603-6895
Your browser does not support capabilities required for electronic signatures.