Intravaneous Nutrient Therapy Consent

 

I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, proper exercise, proper diet and nutritional supplementation). I understand that an initial series of treatments are anticipated and typically needed to help correct nutrient deficiencies and that these treatments may extend over a number of weeks or months. I understand that it is my option to stop at any time with this treatment protocol without incurring any further expense after I have directed that such treatment be stopped. As with any other medical procedure, a small percentage of clients do not respond to this therapy. 

This procedure involves inserting a needle into your vein or muscle and injecting the formula prescribed by your practitioner.  Alternatives to intravaneous therapy are oral supplementation and dietary/lifestyle changes. 

Risks of intravaneous therapy include but are not limited to discomfort at the infection site, thrombophlebitis, allergic reaction, congestive heart failure, anaphylaxis, cardiac arrest, and death. I understand that this therapy should not be used if I am pregnant without a direct order from my treating OB/GYN.

The procedure will be performed by or under the direction of the Nurse Practitioner by qualified personnel. 

 

Potential benefits of Intravaneous Therapy include: 

Injectables/Infusions are not affected by stomach or intestinal  disease. 

Total amount of infusion is available to the tissues. 

Higher doses of nutrients can be given than possible by mouth without intestinal irrittion. 

 

I understand the nature of the proposed therapy and the risks and dangers have been explained to me to my full satisfaction.

While I understand that there have been no warranties or guarantees of successful treatment made to me, I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations and materials that may be provided to me by the office to educate me about the treatment. I acknowledge that I have had the opportunity to ask questions and with respect to my proposed therapy and the treatments to be utilized and all my questions have been answered to my full satisfaction.

Additionally, I am agreeing that I have disclosed my full medical history to the health care practitioner and I authorize and consent to the performance of the procedure(s). 

I agree to indemnify, defend, protect, and hold harmless the medical providers employed by or contractors utilized by Adaptiv Wellness and Recovery; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Adaptiv Wellness and Recovery; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by Adaptiv Wellness and Recovery;; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Adaptiv Wellness and Recovery;. I am aware of the potential side effects associated with IV infusion and injectable therapies provided by Adaptiv Wellness and Recovery, accept all the risks involved with IV infusion and injectable therapies, and will not seek indemnification or damages from the indemnified parties.

My signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of intravenous nutrient therapy in my case and/or any other medical treatments that may be necessary as a result thereof.