The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, nutrients (vitamins, minerals, amino acids).
This document is intended to serve as confirmation of informed consent for IV therapy for hydration.
-I have informed the medical provider/practitioner of all current medications and supplements.
-I have also informed the medical provider/practitioner of any known allergies to drugs or other substances, or of any past reactions to anesthetics.
-I was notified by the medical provider/practitioner and understand the risks and benefits of IV therapy, quick and easy vitamin boosts, and effective weight loss support therapy.
Products and Services
-We are providing IV and injection vitamin boosts. Vitamins and minerals are essential for the cells to function properly.
-Vitamin boosts and infusions are the fastest, most efficient way for your body to receive hydration and micronutrients.
-These essential nutrients are delivered in to the bloodstream where your cells can begin to uptake what your body needs right away.
This document is intended to serve as confirmation of informed consent for IV therapy and boost
I understand that risks, benefits and alternatives to IV therapy may include but are not limited to:
1. The Risks and potential side effects
o Discomfort, bruising, and pain at the site of injection.
o Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
o Severe reaction, anaphylaxis, cardiac arrest, or death.
2. The Benefits
o Injectables are not affected by stomach or intestinal disease.
o Total amount of infusion is available to the tissues
o Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth.
3. 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.
4. 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.
5. 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.
I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.
The procedures set forth above has been adequately explained to me by my Dr. Dagmar Ngiowa, DNP, NP-C. 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.