Informed Consent for Medical Procedures

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Name* This field is required.
First Name
Last Name
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Procedure* This field is required.
Intravenous IV Therapy (drip)
Intramuscular injection (shot)
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Informed Consent

1. I understand that I have the right to consent or refuse any procedure at any time prior to its performance.

2. I assume full liability for any adverse effects that may result from non-negligent administration of the proposed procedure.

3. I have the capacity to reason and make judgments.

4. I make this decision voluntarily and without coercion.

5. I have a clear understanding of the risks and benefits of the proposed treatment alternatives or nontreatment. They have been explained and my questions answered.

6. I am aware that unforeseeable complications could occur, and I do not expect you to anticipate and explain all possible risks and complications.

7. I understand the purpose of the procedure needed for my treatment. I know the practice of medicine is not an exact science. I know that NO GUARANTEE can be made about the outcome.
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Risk

I understand the medical risks and results including: For intravenous (IV) therapy, allergic reaction, infection, discomfort, bruising, pain, inflammation, phlebitis, infection, metabolic disturbances, hypothermia, embolism, cardiac arrest, and even death (very unlikely). For intramuscular injections, allergic reaction, discomfort, bruising, pain, inflammation, numbness and tingling, drainage at injection site, prolonged bleeding, nerve damage, burning, soreness at site.
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Other Options

I have been told of any reasonable other treatment choices. I know the risks and results of these other choices. These include, but are not limited to: Talking to your primary care provider to determine other options. These may include oral supplementation and dietaryand lifestyle changes.

I have also been told of the risks and results of having no treatment:
The risks are that you will remain in the same situation you are now, with the same symptoms. While it is possible you may experience a worsening of symptoms, that is an issue to discuss with your primary medical provider.
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Signature* This field is required.I hereby instruct you to perform the procedure and agree to the above release. I also verify that all information presented to you in my medical history is true to the best of my knowledge and that I am not misrepresenting myself. I hereby acknowledge that this is a self-pay service, no medical insurance is accepted, and all payments are non-reimbursable. I agree to be responsible for the payment at the time of service for all services, including non-covered services.
Clear
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Date* This field is required.
Date
Year
Month
Day
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