Intravenous (IV) Nutrient Therapy Consent Form
This document is intended to serve as informed consent for your Intravenous (IV)Nutrient Therapy as ordered by the physician at Graham Plastic Surgery
I have informed the nurse and/or physician of any known allergies to medications or other substances and of all current medications and supplements. I havefully informed the nurse and/or physician of my medicalhistory.
Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intendedto diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician’s medicalcare.
I understand that IV Nutrient Therapy at Graham Plastic Surgery is only for otherwise healthy adults under the age of60.
I understand that I have the right to be informed of the procedure, any feasible alternative options,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.
I understand that:
1. The procedure involves inserting a needle into a vein and injecting the prescribedsolution.
2. Alternatives to intravenous therapy are oral supplementation and / or dietary andlifestyle changes.
3. Risks of intravenous therapy include but not limited to: a) Occasionally: Discomfort, bruising and pain at the site of injection. b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest anddeath.
4. Benefits of intravenous therapy include: a) Injectables are not affected by stomach, or intestinal absorption problems. b) Total amount of infusion is available to the tissues. c) Nutrients are forced into cells by means of a high concentration gradient. d) Higher dosesof nutrients can be given than possible by mouth without intestinalirritation.
I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or physician(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or physician(s) to exercise judgment during thecourse of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questionsanswered.
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 Nutrient Therapy,including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may beindicated.
My signature below confirms that:
1. I understand the information provided on this form and agree to the all statements made above.
2. Intravenous (IV) Nutrient Therapy has been adequately explained to me by my nurseand/or physician.
3. I have received all the information and explanation I desire concerning theprocedure.
4. I authorize and consent to the performance of Intravenous (IV) NutrientTherapy.