• INTRAVENOUS OZONE & ULTRAVIOLET BLOOD IRRADIATION


  • Patient information, instructions, informed consent, and release of liability.

    OZONE: www.oxygenhealingtherapies.com

    ULTRAVIOLET BLOOD IRRADIATION:
    The use of ultraviolet light to treat pathogenic organisms (infections) dates back to the early 1900s. The Nobel Prize was awarded to a Danish physician in 1903 for his development of ultraviolet (UV) therapy for skin infections. The concept was later adapted for treatment of internal infections. This therapy was found to be safe and effective, and was widely used in hospitals until the advent of antibiotics.
    UV irradiation of the blood has multiple effects within the body. The immune, nervous and cardiovascular systems and blood components are impacted. Exposure of the blood to UV light activates oxygen molecules, leading to a number of positive biochemical changes at the cellular level. An environment is created that supports cells' natural ability to respond to threats such as bacteria and viruses. The blood is purified and resistance to infections rises. Oxygen is also more readily absorbed by the blood and diffusion to the cells is increased. An abundant oxygen supply is critical to all cells and has important ramifications for immune cell function. Additional effects include normalization of blood cell numbers and function, improved blood flow and a positive influence on the autonomic nervous system. Because of these many benefits, ozone and ultraviolet blood irradiation (MAH/UVB) may be useful in the treatment of a wide range of conditions including:

    • Autoimmune disease
    • Adjunctive Cancer therapy
    • Chronic Fatigue Syndrome
    • Vascular disorders (e.g. Reynaud's, P.A.D.)
    • Acute & Chronic Infections
    • Hepatitis C
    • Biotoxin Illness (mold, Lyme, mycoplasma)
    • Non-healing wounds


    The Procedure:
    Treatment of a patient's blood with ozone and ultraviolet light are generally combined into one procedure, although they may be performed separately. While seated or reclined in our comfortable treatment room, a standard intravenous (IV) line is inserted. Through this IV, blood is withdrawn, treated with ozone, and reinfused through specialized tubing that allows for exposure to the ultraviolet light. The treatment lasts approximately one hour.
    A series of treatments is necessary to fully address any condition. Typically one session per week is advised, however the frequency and total number of sessions will be determined by each doctor on an individual basis.

    Patient Preparation:
    You SHOULD NOT receive UBI/Ozone if you have any of the following conditions:

    • Hyperthyroidism
    • Active Bleeding or Acute Hemorrhagic disease (e.g. hemophilia)
    • Acute MI (heart attack)
    • Women - Pregnant or Lactating
    • Alcohol intoxication or withdrawal
    • Major surgery in the past 6 weeks


    PLEASE TELL US IF ANY OF THE FOLLOWING APPLY TO YOU:

    • Porphyria
    • Subacute Cholecystitis
    • Fever of unknown origin
    • Use of Prescription Steroids (e.g. prednisone, cortisone)

    You will need to STOP ANY OF THE FOLLOWING MEDICATIONS and/or SUPPLEMENTS 2 DAYS BEFORE THE TREATMENT:

    • Sulfur based Antibiotics: Septra, Bactrim, Sulfadiazine, Sulfisoxazole, Dapsone Sulfur based Medications: Sulfonylureas, Sulfasalazine, Celebrex, Imitrex, Zonisamide Any Photosensitizing Medications/Nutrients:
    • Tetracyclines (Doxycycline, Minocycline)
    • Quinolone/Fluoroquinolone antibiotics (Ciprofloxacin, Levofloxacin & others) Erythrosine, Rose Bengal, Rhodamine, Acridine dyes, Adriamycin, Methyl Blue,
    • Quinine, Porphyrins, 8-MOP
    • Acutane (tretinoin), Vitamin A
    • Aspirin, Celebrex, Mobic, ibuprofen


    ON THE DAY OF YOUR TREATMENT:

    • Hydration: Please drink several (4 to 6) glasses of water during the 2 hours prior to your appointment. Please bring a water bottle with you.
    • Nutrition: To prevent complications of low blood sugar, please eat a balanced breakfast or lunch before your appointment. Also, bring a high protein/high carbohydrate snack with you (e.g. fruit with nuts, cheese or yogurt; a sandwich).

    Informed Consent for Ultraviolet Blood Irradiation/Ozone
    My healthcare provider has recommended that I be treated using Ultraviolet Blood Irradiation (UBI)/Ozone. By signing this form and based on the information that has been provided to me, I am consenting to and authorizing the procedure. I also understand that in many cases a series of 4-12 sessions over several weeks or months is generally recommended, depending on my response to treatment. I have been provided with an opportunity to discuss this treatment with my provider and my questions have been answered.

    Description: During the procedure, approximately 60cc of blood is withdrawn from the patient and placed into a bag containing saline. A small dose of heparin will be required to prevent blood clotting. The blood will be treated with ozone and reinfused through specialized tubing that passes through a device that exposes it to UV light. The blood then travels back to the patient's vein. The treatment lasts approximately one hour.

    Brief description of potential benefits: Most proponents of UBI believe that the benefits they have observed in clinical practice relate to the deleterious effect of UV light on the DNA of circulating microorganisms. In human cells, the genetic material (or DNA) resides in the nucleus of the cell. Human red blood cells are unique in that they don't have a nucleus and are therefore relatively safe from these effects. White blood cells have a nucleus with DNA but they also have an enzyme system that repairs DNA and is activated by UV light. UBI is therefore selectively toxic to blood pathogens. It's not practical to irradiate more than 1-5% of the total blood volume, but this may be enough to up regulate the systemic immune response to any blood pathogens that are killed or weakened by the therapy.

    Risks: The probability of sustaining a permanent injury related to UBI is low. A Russian study on UBI (available at www.ncbi.nlm.nih.gov/pubmed/20779721) documented complications in 12 of 2,380 sessions: shivering (4 cases), hypotension (aka decreased blood pressure, 2 cases), epistaxis (aka nosebleeds, 3 cases), hypoglycemia (low blood sugar, one case), bronchospasm (the kind of wheezing seen is asthmatics, I case), and rash (consistent with hives, 1 case). Most IV therapies carry some risk of local swelling, bruising or irritation at the catheter insertion site. In the same Russian study, the total combined incidence of these complications was 1.3%.

    Contraindications: We do not recommend UBI in patients who suffer from porphyria: this group of rare inherited blood disorders often manifests as skin sensitivity to sunlight. Patients who seem highly sensitive to UV light on their skin should be tested for porphyria before getting UBI.

    Cost: Insurance carriers consider UBI to be an experimental procedure and do not cover the cost. There are no CPT codes to describe UBI so it is not possible to submit a claim.

    Payment in full is due at the time of service.

    Expectations: Neither The Montana Clinic nor any of its providers and employees makes warranties or guarantees about the efficacy of UBI for any given condition.
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  • I, representing that I am of sound mind and not currently under the influence of any alcohol or drugs, hereby give consent to Two Sparrows Wellness and Beauty Bar (April Haugrose) and The Montana Clinic and its employees, including any Doctor, Nurse, or Staff Member associated with MT Clinic to administer to me, Ultraviolet Blood Irradiation (UBI) with ozone therapy. The rationale for UBI/ozone has been explained to me and I have had the opportunity to ask questions. I have reviewed the provided information sheet.

  • I, understand that UBI/Ozone is not FDA approved.

  • I, understand that UBI/Ozone should not be considered as an "alternative" or "substitute" for hospital based care in the case of serious infection, and I understand that antibiotic therapy may be appropriate even if I am receiving UBI/Ozone. However, I understand that I should not take a sulfa antibiotic for five days post-UBI. I understand that I might experience a "die off" or "Herxheimer" reaction post-UBI/Ozone related to the rapid destruction of invading organisms, and that this may take the form of malaise, fatigue, achiness, and sweats.

  • I, I understand if I am receiving UBI/Ozone to address asthma, I understand that I might experience an asthma attack the night of my first UVBI, and thus I will keep my anti-asthma medications close at hand.

  • I, understand that heparin, an anticoagulant, will be used to prevent clot formation within my blood (when it is external to my body in the IV tubing, UV device, or syringe), and that I will experience a transient and mild anticoagulant effect when the heparinized blood is re-infused. I further understand that abnormal bleeding has not been reported in the published UBI literature. Nonetheless, if I have any known bleeding tendencies or medical conditions associated with easy bleeding, I will relate these prior to undergoing UBI.

  • I, understand that UBI involves placement of an intravenous catheter, which always entails a small risk of infection, bleeding, or superficial clotting and bruising at the puncture site.

  • I, understand that UBI is not covered by Medicare or any other insurer. As such, my insurer will not be billed for this service and I agree to reimburse The Montana Clinic for the cost of UVBI at the time of service.

  • Having read this document, the procedure description and information sheet on UVBI/Ozone. I wish to receive UBI.

  • WAIVER AND RELEASE OF LIABILITY

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  • In consideration of the risk of injury while participating in UVBI/Ozone therapy services (the "Activity"), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the activity, and do hereby release and forever discharge Two Sparrows Wellness and Beauty Bar and The Montana Clinic, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned activity, including traveling to and from an event related to this activity.

  • I am voluntarily participating in the aforementioned activity, I am aware of the possible risks and I am participating in this activity entirely at my own risk.

  • I agree to indemnify and hold harmless Two Sparrows Wellness and Beauty Bar(April Haugrose, Nicole Brown, Brooke Kennedy or any other affiliates) and The Montana Clinic against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any to any claims made by me or by anyone else acting on my behalf. If Two Sparrows Wellness and Beauty Bar and The Montana Clinic incurs any of these types of expenses, I agree to reimburse Two Sparrows Wellness and Beauty Bar and The Montana Clinic. I acknowledge that Two Sparrows Wellness and Beauty Bar and The Montana Clinic and their directors, officers, volunteers, representatives, and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Two Sparrows Wellness and Beauty Bar and The Montana Clinic.

  • I agree to indemnify and hold harmless Two Sparrows Wellness and Beauty Bar(April Haugrose, Nicole Brown, Brooke Kennedy or any other affiliates) and The Montana Clinic against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any to any claims made by me or by anyone else acting on my behalf. If Two Sparrows Wellness and Beauty Bar and The Montana Clinic incurs any of these types of expenses, I agree to reimburse Two Sparrows Wellness and Beauty Bar and The Montana Clinic. I acknowledge that Two Sparrows Wellness and Beauty Bar and The Montana Clinic and their directors, officers, volunteers, representatives, and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Two Sparrows Wellness and Beauty Bar and The Montana Clinic.

  • I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Two Sparrows Wellness and Beauty Bar and The Montana Clinic AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Two Sparrows Wellness and Beauty Bar and The Montana Clinic FOR PERSONAL INJURY OR PROPERTY DAMAGE. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Two Sparrows Wellness and Beauty Bar and The Montana Clinic, its agents, and employees. In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment, I am aware and understand that I should carry my own health insurance. In the event that any damage to equipment or facilities occurs as a result of my or my family's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the participant, and Two Sparrows Wellness and Beauty Bar and The Montana Clinic agree that this agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.

  • I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.

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  • PARENT/GUARDIAN WAIVER FOR MINORS

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  • In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
    I hereby certify that I am the parent or guardian of this patient.

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