I understand that:
1) The procedure involves inserting a sterile needle into a muscle or a vein and infusing the desired item from the INFUZE menu directly into your body.
2) An alternative to intravenous therapy is oral supplementation
3) Risks of intravenous therapy include but not limited to:
a) Occasionally to commonly
i) Discomfort, bruising and pain at the site of injection
i) Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury
c) Extremely Rarely
i) Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death
d) Benefits of intravenous therapy and injectable supplements include:
i) The ability to provide prompt fluid replacement and hydration
ii) The total amount of the infusion is available to the tissues.
iii) Nutrients are forced into cells by means of a high concentration gradient.
iv) Higher doses of nutrients can be given without causing intestinal irritation, during bouts of nausea or vomiting, easy to monitor delivery, and provide immediate results.
Your signature below means that:
1. You have read and understand the information provided in this form
2. The procedure has been adequately explained and all your questions have been addressed
3. You have received all the information and explanation you desire concerning the procedure
4. You authorize and consent to the performance of the procedure as agreed upon with INFUZE.
5. You are of sound mind and able to make a rational decision
By signing this consent, I acknowledge that the risks, benefits and alternatives have been discussed and explained to me. The procedure has been adequately explained and all of my questions have been addressed. I have been advised that this procedure may be beneficial in my condition. I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND ALL MY QUESTIONS HAVE BEEN ANSWERED.