This document is intended to serve as confirmation of informed consent for Intravenous (IV) Therapy as ordered by the providers at Arctic Medical Center, Dr. Johannes Gruenwald, MD and/or Erika Dominick, CRNP. I understand that I have the right to be informed before the procedure of both risks and benefits. Procedures are not performed until I have had the opportunity to receive such information and to give my informed consent. The IV procedure involves inserting a needle into my vein and infusion a predetermined bag of nutrients (vitamins, minerals, amino acids, etc).
Risks and potential side effects:
- Dicomfort, bruising, pain, and/or infection at the site of vein access
- Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury
- Dizziness, headache, flushing, chills, stomach pain, heaviness in chest, diarrhea, constipation, flu-like symptoms, body aches, drowsiness, sever reaction, anaphylaxis, cardiac arrest, or even death
I am aware that other unforeseeable complications could occur. 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 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 added procedure in which the opinion of my provider my be indicated.
I understand the information on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of the chosen treatment. The procedure(s) set forth has/have been adequately explained to me by the provider at Arctic Medical Center. I understand that I am free to discontinue participation in this treatment at any time.
My signature below confirms that:
- I have received all of the information and explanation I desire concerning the procedure(s)
- I authorize and consent to the performance of the procedure(s)
- To the best of my knowledge I do not have Kidney Disease, Congestive Heart Failure, or Renal Disease
- I have informed the provider of any known allergies to medications, anesthetics, or other substances that may be included in the ingredients of my solutions
- I have informed the provider of all current medications and supplements
- All of my questions and concerns have been addressed and answered