Methylene Blue Capsules for Neuroprotection and Brain Health

Methylene Blue Capsules for Neuroprotection and Brain Health

Once this order form is completed, you have paid for the prescription as well as the capsules. The Doctor will send in the prescription and the capsules will be shipped to you.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
CONSENT FOR TREATMENT WITH METHYLENE BLUE CAPSULES 1. PURPOSE OF TREATMENT: I, the undersigned, hereby consent to treatment with methylene blue capsules prescribed by Dr. David Mahjoubi, MD at the IV Healing Spa. Methylene blue is an agent that may be used for various conditions, including cognitive enhancement, energy improvement, and as an adjunct for certain health conditions. I understand that methylene blue is not FDA-approved for these uses and is considered an off-label treatment. 2. POTENTIAL BENEFITS I understand that while methylene blue may offer potential benefits, including improved mental clarity, increased energy, and support for cellular function, no specific therapeutic outcome can be guaranteed. Results may vary from patient to patient, and there is no certainty that I will experience any particular benefit. 3. POTENTIAL SIDE EFFECTS I acknowledge that taking methylene blue capsules may have side effects, which include but are not limited to: Common Side Effects: Nausea or gastrointestinal discomfort HeadacheDizziness Mild stomach upset or diarrhea Discoloration of urine, which may appear blue or green Less Common but Serious Side Effects: Hemolytic anemia, particularly in individuals with G6PD deficiency Shortness of breath or chest pain Confusion or mood changes Serotonin syndrome, especially if taken with other serotonergic medications (examples include Celexa, Lexapro, Prozac, Paxil, Pexeva, Brisdelle, Zoloft, Cymbalta, Pristiq, Fetzima, Savella, Effexor, Elavil, Anafranil, Norpramin, Sinequan, Tofranil, Pamelor, Surmontil, Marplan, Nardil, Emsam, Parnate, St Johns Wart). Allergic reactions, including rash, itching, swelling, or severe dizziness I understand that these side effects may range in severity, and in rare cases, they may lead to serious health complications requiring medical attention. 4. RISKS ASSOCIATED WITH TREATMENT I understand that the use of methylene blue involves risks that include, but are not limited to: Potential Drug Interactions: Methylene blue may interact with certain medications, including antidepressants, antipsychotics, and other serotonergic drugs, which could lead to serotonin syndrome or other complications. I have disclosed all medications and supplements I am currently taking to my healthcare provider. Unpredictable Individual Responses: Due to genetic, metabolic, or other individual factors, my response to methylene blue may differ from others and may involve unexpected side effects or lack of effectiveness. Unknown Long-Term Effects: As methylene blue is used off-label, the long-term effects and safety profile are not fully established. 5. ACKNOWLEDGMENT OF NO GUARANTEE OF BENEFITS I understand that the IV Healing Spa and Dr. David Mahjoubi, MD make no guarantee, either expressed or implied, that I will experience any specific benefit from taking methylene blue capsules. I have been informed that the results may vary widely, and any potential benefits are not assured. 6. ALTERNATIVE TREATMENTS I understand that I am under no obligation to take methylene blue and that alternative treatments are available. I have discussed these alternatives with my healthcare provider and understand the potential benefits and risks associated with each option. 7. VOLUNTARY CONSENT I have read and fully understand the information provided in this consent form. I have the option to discuss the treatment with Dr. David Mahjoubi, MD and ask any questions about the potential benefits, side effects, and risks. I do not have any questions. I understand that I may withdraw my consent at any time. By signing this form, I confirm that I voluntarily consent to treatment with methylene blue capsules, understanding the potential risks, side effects, and the absence of guaranteed benefits.*

Powered by Jotform SignClear
Date*

MonthDayYear
Date

My Products*

5 mg Capsules 60 capsules

$120.00 Quantity

15 mg Capsules 60 Capsules

$200.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please list all prescription and over the counter medications you take. Please write "none" if you do not take any medications or supplements. *
Should be Empty: