IV Consent

The administration of intravaneous vitamins, minerals, and nutrients is a procedure that is recommended for the replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects such as improving immune function, improving antioxidant status, reducing oxidative damage, decreasing bronchospasm, improving fatigue, boosting muscle recovery, and energy efficiency.

By checking "I agree", you authorize the administration of intravenous vitamins, minerals, and other nutrients.*

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By checking "I agree", you confirm that you have informed the nurse and/or physician of all medical history, any known allergies to medications or other substances, and all current medications and supplements.*

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By checking "I agree", you understand that intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician’s medical care.*

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By checking "I agree", you understand that you have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent.*

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By checking "I agree", you understand that the procedure involves inserting a needle into a vein and injecting the prescribed solution.*

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By checking "I agree", you understand that alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.*

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By checking "I agree", you understand that risks of intravenous therapy include but are not limited to: a) Occasionally: Discomfort, bruising and pain at the site of injection. b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.*

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By checking "I agree", you understand that pregnancy is contraindicated for all IV infusion therapies. It is advised to take an at home pregnancy test to rule out this condition before your treatment. Please inform a staff member if you think you might be pregnant.*

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By checking "I agree", you understand that the benefits of intravenous therapy include: a) Injectables are not affected by stomach, or intestinal absorption problems. b) Total amount of infusion is available to the tissues. c) Nutrients are forced into cells by means of a high concentration gradient. d) Higher doses of nutrients can be given than possible by mouth without intestinal irritation.*

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By checking "I agree", you are confirming that you are aware that other unforeseeable complications could occur. You do not expect the nurse(s) and/or physician(s) to anticipate and or explain all risk and possible complications. You rely on the nurse(s) and/or physician(s) to exercise judgment during the course of treatment with regards to my procedure. You understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.*

I agreeI do not agree

By checking "I agree", you understand that you have the right to consent to or refuse any proposed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent to IV Infusion Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.*

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This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health.

Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the doctors and other health professionals at RevolutionaryMD as is appropriate and necessary for my care.

I further understand and agree to adhere to the treatment schedule and attend the follow-up visitations set by my medical provider to permit observation and study of my progress. I understand that I may suspend or terminate my treatment at anytime by informing my medical provider. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated.

I hereby place myself under your care for intravenous vitamin therapy. I also verify that all information presented to medical provider in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment for these conditions.

I hereby acknowledge that I understand that my insurance coverage, including Medicare, may not pay for this non‑covered service, and that all services ancillary to this treatment may be also non-covered services and non-reimbursable. I agree to be responsible for payment at the time of service for all non-covered services.

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Revolutionary MD IV Consent