Consent for IV Therapy Treatment
I understand that:
- The procedure involves inserting a needle into a vein and injecting the prescribed solution.
- Alternatives to intravenous therapy are oral supplementation and/ or dietary and lifestyle changes.
- 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:
- I understood the information provided on this form and agreed to the foregoing.
- The procedure(s) set forth above has been adequately explained to me by my provider
- I have received all the information and explanation I desire concerning the procedure.
- I authorize and consent to the performance of the procedure.
- 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.