This informed consent form explains the risks and benefits of intravenous (IV) cannabidiol (CBD) infusion. Please read this form carefully and ask any questions you may have before signing. IV infusions of CBD involve administering CBD directly into your bloodstream. 

1. Informed Consent: You will be asked to read and sign this informed consent form, indicating your understanding and voluntary agreement to the procedure.
2. Medical Informed Consent Evaluation: A healthcare professional will review this form with you prior to your infusion.
3. IV Insertion: A qualified healthcare provider will insert an intravenous catheter into a vein in your arm.
4. CBD Infusion: CBD will be diluted in a sterile solution and administered through the IV line over a predetermined period.
5. Monitoring: A healthcare professional will be present at all times during your infusion.

CBD has shown potential therapeutic benefits in managing various conditions, including:

• Anxiety
• Chronic pain
• Inflammation
• Insomnia

Do you have any known active infections?

These would include:

• A cold or the flu
• A urinary tract infection
• A skin infection
• Any other infection

If you have an active infection, it may be necessary to postpone your IV CBD infusion until the infection is resolved. This is to minimize the risk of complications and ensure your safety. Please be honest and upfront about any health concerns you may have.

• Tightening of chest
• Dizziness
• Euphoria
• Nausea
• Flushing - skin reddening
• Allergic reaction 
• Fever
• Chills

 

 

Please be aware that the IV infusion may be administered in a public area. While we make every effort to maintain patient privacy, please understand that there may be other persons present during your infusion. If you have concerns about privacy, please discuss them with the staff before consenting to the procedure. We will do our best to accommodate reasonable requests for increased privacy within the constraints of our location.

The information provided in this form is for educational purposes only and does not constitute medical advice. Please consult with a qualified healthcare provider to determine if CBD infusion is an appropriate treatment option for you.

I grant PICO IV, its employees, agents, licensees, and assigns (hereinafter referred to as "Company"), the irrevocable and unrestricted right and permission to use and publish photographs and/or video recordings of me (hereinafter referred to as "Images") in any and all forms and media, whether now known or hereafter devised, including but not limited to:

Promotional materials: Brochures, flyers, advertisements, websites, presentations, etc.

Social media: Posts, stories, and advertisements on platforms like Facebook, Instagram, Twitter, etc.
Internal communications: Company newsletters, emails, reports, etc.

I understand and agree that the Company may use the Images for any lawful purpose, including commercial purposes, and that the Images may be used with or without my name.

I waive any right to inspect or approve the finished Images or any printed or electronic matter that may be used in conjunction with them.

I hereby release and discharge the Company from any and all claims and demands arising out of or in connection with the use 1 of the Images, including without limitation any 2 claims for libel, invasion of privacy, or right of publicity.

The information provided in this form is for educational purposes only and does not constitute medical advice. Please consult with a qualified healthcare provider to determine if CBD infusion is an appropriate treatment option for you.

This consent form is designed to provide you with important information about IV CBD infusion. We encourage you to ask any questions you may have before, during, or after the procedure. If you have any questions or concerns, please do not hesitate to speak with a member of our healthcare team. You can also contact us at 855-900-0020. We are here to support you and ensure you feel comfortable and informed throughout the process.

I have read and understood the information provided in this form. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily consent to receive intravenous (IV) therapy from a licensed registered nurse (RN) contracted by Wallace Brucker, MD, Reform Me, LLC. I understand that these RNs are independent contractors licensed in the state of Nevada.