This document is intended to serve as confirmation of informed consent for Intravenous (IV) Therapy as ordered by the providers at Arctic Medical Center. I understand that I have the right to be informed before the procedure 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 infusing a predetermined bag of nutrients (vitamins, minerals, amino acids, etc).
Disclosure: NAD⁺ (nicotinamide adenine dinucleotide) and glutathione used in injectable or intravenous (IV) form are not approved by the U.S. Food and Drug Administration (FDA) for the diagnosis, treatment, cure, or prevention of any disease. Their use in this setting is considered off label.
Purpose of Use: These substances may be offered to support energy metabolism, cellular function, detoxification, or general wellness. Reported benefits are based on clinical experience, scientific literature, or patient-reported outcomes.
Voluntary Participation: Receiving NAD⁺ or glutathione injections/IV infusions is completely voluntary. You may decline or discontinue treatment at any time without affecting your access to other services.
Risks and potential side effects:
- Discomfort, 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, severe 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 may 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
- 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