IV Referral 2021

IV Therapy Intake Form
This document is intended to serve as a confirmation of informed consent for IV Therapy as ordered by the provider at Dr. Vivian Asamoah Gastroenterology. It should be completed annually by each participating patient.
I am enrolling in DVA Renewed Balance IV/Detox Program *
**Enrollment in DVA Renewed Balance Program includes detox supplements and infrared sauna usage, please see below for additional consents.
Date *

Month Day Year
Name *

First Name Last Name
Date of Birth *

Month Day Year
Phone Number *
Please enter a your best contact number.
Email *
example@example.com
How did you hear about us?
What are your main complaints? *

Anticipating or recent surgical procedure Asthma or Allergies Brain fog or trouble concentration Fatigue/ Low Energy Headaches or migraines Low mood or depression Malabsorption issues Poor diet due to busy lifestyle Recent Illness SIBO detox Stress Weight gain or difficulty losing weight
(Females only) Are you currently pregnant or breastfeeding?

Yes No
Date of last labs:blanks*. Please submit a copy of the labs below if you have the following Complete Blood Count, Comprehensive Metabolic Panel within the last 90 days
Take Photo
Have you ever been told that you have an electrolyte imbalance or other abnormal labs? (Please check all that apply) *

Vitamin B 12 Deficiency Vitamin D deficiency Antioxidant deficiency such as Glutathione Hypercalcemia/High calcium Levels Hypermagnesium/High Magnesium Levels Hypokalemia/Low Potassium Levels Hemochromatosis/High iron levels Other
Please list any drug allergies and reactions below
Do you have any of the following conditions? (Please check all that apply) *

Blood pressure (High or Low) Heart problems Stroke or "mini stroke" Kidney problems Diabetes (1 or 2) Diarrhea Kidney stones Autoimmune condition(s) Cancer Sickle Cell Anemia G6PD Deficiency Parathyroid problems
Acknowledgement of Non- Insurance Coverage for Services Rendered *

I agree, and it has been explained to me, that the following services performed at Dr. Vivian Asamoah Gastroenterology are not generally considered and accepted w/ respect to insurance coverage. Usual and customary Evaluation and Management or other medically necessary services may be billable to my insurance, but IV/Injection services and supplies cannot be billed. I understand that this requires my payment in full for all IV/Injection services, supplies and I additionally understand that I may not attempt to bill my own insurance company for any of these services. Insurance deems these therapies investigational/experimental.
*

I have informed the provider of any known allergies to drugs or to other substances, or of any past reactions to anesthetics. I have informed the doctor of all current medications and supplements.
Consent for IV Therapy Treatment

I understand that:
1. The procedure involves inserting a needle into a vein and injecting the prescribed solution.
2. Alternatives to intravenous therapy are oral supplementation and/ or dietary and lifestyle changes.
3. Risks of intravenous therapy including but not limited to:
  - Occasionally to commonly:
    
    Discomfort, bruising, and pain at the site of injection.
    
    Rarely:
    
    Inflammation of the vein used for injections, phlebitis, metabolic disturbances, and injury.
    
    Extremely Rarely:
    
    Severe allergic reaction, anaphylaxis, infections, cardiac arrest and deaths.
    
    Benefits of Intravenous therapy include:
    
    Injectables are not affected by stomach or intestinal absorption problems
    
    Total amount of infusion is available to the tissues
    
    Nutrients are forced into cells by means of the high concentration gradient
    
    Higher dose of nutrients can be given than possible by mouth without intestinal irritation.
I am aware that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and or explain all risks and possible complications. I rely on the provider(s) to exercise judgment during the course of treatment with regard to my procedure. 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. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedures which, in the opinion of my provider(s) or others associated with this practice, may be indicated.

I understand that all nutrient infusions given at Dr. Vivian Asamoah Gastroenterology are considered investigational/experimental. These infusions are not considered standard of care and are not billable to insurance.

My signature below confirms that:
1. I understood the information provided on this form and agreed to the foregoing.
2. The procedure(s) set forth above has been adequately explained to me by my provider
3. I have received all the information and explanation I desire concerning the procedure.
4. I authorize and consent to the performance of the procedure.
5. I understand the intravenous therapies provided are experimental and may not be approved by the United States Food and Drug Administration for the treatment of my medical condition.
Renewed Balance Participants ONLY:

I am enrolling in Renewed Balance program. Retail valued at $1,195, I am enrolling for the promotional price of $975. I understand this includes 6 weeks of combination IV and Sauna along with detox supplements. With my signature below I am also acknowledging I confirm that I have read the advice and contraindications, and that I do not have any contraindications to the Infrared Sauna, or that my contraindications have been discussed with my provider and have been cleared for usage. I understand that the sauna is not intended to take the place of medical care, medications, or treatment for any medical condition. I agree to adhere to the usage rules and guidelines as set by the Office of Dr. Vivian Asamoah. I understand that I take full responsibility for my own health and well-being. I release the Office of Dr. Vivian Asamoah, its providers, employees and technicians from all liability associated with using the Infrared Sauna.
Signature *

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IV Therapy Intake Form