Informed Consent Intravenous Therapy
- I, hereby authorize the following procedures:Administration of Intravenous vitamins, minerals, and other nutrients.
The principal side effects that may accompany intravenous administration of nutrients includes:
- This procedure is recommended for replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidants status, reducing oxidative damage, improving fatigue, etc.
- burning and stinging at the site of infusion or if IV infiltration into surrounding tissue
- muscle spasms weakness or fatigue
- allergic reactions (rare)
- local thrombophlebitis (very rare).
- This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is a potential benefit in these circumstances and its use all quite probably improvement the condition for which you are under treatment and it all your in your overall health..
- Based on the risk and potential benefits of the current medically indicated treatments and of this proposed treatment, I have elected to forego or supplement the indicated treatment and receive the proposed treatment from Licensed health professionals at TK “H2O” IV Hydration and Wellness,LLC mobile, as is appropriate and necessary for my care.
- I understand that I may suspend or terminate my treatment at any time by informing my licensed medical team. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity of redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to the negligent administration of this procedure. The risk involved and the possibilities of complication have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer- reviewed publications and therefore may be considered medically unnecessary or not currently indicated. I hereby placed myself under care for intravenous vitamin therapy and agree to the above release . I also verify that all information presented to TK “ H2O” IV Hydration and Wellness, LLC in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under care for the sole purpose for treatment for these condition.
- I hereby acknowledge that I am responsible for payment at this time of service and no insurance will be accepted for treatment.