This document is intended to serve as informed consent for your Intravenous (IV) infusion therapy. 

• I have informed the nurse or medical provider of any known allergies to medications or other substances and of all current medications & supplements. I have fully informed the medical provider of all my medical history. 

• I understand that intravenous infusion therapy and any claims made about these infusions have not been evaluated by the FDA and are not intended to diagnose, treat, cure or prevent any medical disease. The infusions are not a substitute for physicians medical care. 

• I understand that I have the right to be informed of the procedure, any feasible alternative options and the risks & benefits. Except in emergencies, procedures are not informed until I have the oppurtunity to recieve such information and give my informed consent. 

• I understand that:
  • The procedure involves inserting a needle into a vein and injecting the prescribed solution.
  • Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.

1. The risks of IV therapy include but are not limited to: 
   1. Occasionally: Discomfort, bruising and pain at the sight of injection
   2. Rarely: Inflammation of the vein used for injection, phlebities, metabolic disturbances and injury
   3. Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest & death 

1. Benefits of IV therapy include:
   1. Injectables are not affected by stomach or intestional absorption problems. 
   2. Total amount of infusion is avalible to the tissues
   3. Nutrients are forced into cells by means of a high concentration gradient. 
   4. Higher doese 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 nurses and/or physicians to anticipate and/or explain all risks and possible complications. I rely on the medical provider 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 procedures which, in the opinion of my physicians or others associated with this practice, may be indicated.

• My signature below confirms that:

  1. I understand the information provided on this form and agree to all statements made above.

  2. Intravenous (IV) Infusion Therapy has been adequately explained to me by the nurse/medical provider.

  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.

  5. I release all medical staff from all liabilities for any complications or damages associated with my Intravenous (IV) Infusion Therapy.