Intravenous Infusion Therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration 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.
I understand that I 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 I have had an opportunity to receive such information and to give my informed consent.
1. The procedure involves inserting a needle into a vein and injecting the prescribed solution. Intramuscular injections involve inserting a needle into a large muscle and injecting the solution.
2. Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.
3. Risks of intravenous therapy include but are not limited to: a) Occasionally: Discomfort, pain, and burning 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, cardiac arrest, death, air embolism, fluid overload, medication adverse interactions, and nerve injuries.
4. Benefits of intravenous therapy include: a) Injectables are not affected by stomach or intestinal absorption problems. b) Total amount of the 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.
I am aware that other unforeseeable complications could occur. I do not expect the Nurse Practitioner, Nurse, and/or Physician to anticipate and or explain all the risk and possible complications. I rely on the Nurse Practitioner, Nurses, and/or Physician to exercise judgement during the course of treatment with regards 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 Infusion Therapy including any other procedure which, in the opinion of my health care provider may be indicated. My signature below confirms that:
1. I understand the information provided on this form and agree to all the statements made above.
2. Intravenous (IV) Infusion Therapy has been adequately explained to me by the provider at Southtowns Colon Hydrotherapy. 3. I have received all the information and explanation I desire concerning the procedure. 4. I authorize and consent to the performance of Intravenous (IV) Infusion Therapy.