Intravenous (IV) Infusion/ Micronutrient Draw Consent Form

Please read and agree to each statement.

I have the right to be informed about my health condition and treatment so that I may make an informed decision, whether or not to undergo the Intravenous Therapy, Intramuscular Injection, Micronutrient lab draw procedure after knowing the risks and hazards involved.*

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

(IV Infusion only) I agree that I do not have any of the following medical conditions: Heart Failure, Kidney Disease, Liver Disease, Cirrhosis or Ascites, Recent Heart Attack, Pleural Effusion(s), Pulmonary Edema, Taking Diuretics (e.g., HCTZ, Lasix), Bleeding Abnormalities (e.g., Hemophilia)*

(IV Infusion only) I have listed allergies below or I have circled “No known allergies”.*

Allergies:*

List of Allergies*

I understand Intravenous infusion therapy, intramuscular vitamin injections, micronutrient lab draw and any claims made about these infusions and/or injections have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These treatments are not a substitute for your routine medical care.*

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Procedures are not performed until I have had an opportunity to receive such information and to give myinformed consent.*

I understand that the procedure involves inserting a needing into a vein or muscle and injecting the prescribed solution.*

(IV Infusion only) I understand that the risks of intravenous therapy include but not limited to: [Occasionally]: Discomfort, bruising and pain at the site of injection. [Rarely]: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. [Extremely Rare]: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.*

(IV Infusion only) I understand that the benefits of intravenous therapy include: 1. Injectables are not affected by stomach, or intestinal absorption problems. 2. Total amount of infusion/injection is available to the tissues. 3. Nutrients are forced into cells by means of a high concentration gradient. 4. Higher doses of nutrients can begiven than possible by mouth without intestinal irritation.*

I am aware that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and/or explain all risk and possible complications. I rely on the provider(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of theprocedure and have had the opportunity to have all 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 firm affirms that I have given my consent to IV Infusion and/or IM Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.*

Cancellation Policy: San Antonio Prime Wellness staff allocates time and prepares a vitamin drip kit or IM injection prior to each appointment which cannot be used in the event of a cancellation. We request that you reschedule or cancel your appointment at least 24 hours prior to the start time of your appointment otherwise your appointment and any payment(s) for service(s) will be forfeited.*

I understand that all payments for services to San Antonio Prime Wellness are non-refundable and all sales are final. *

My signature below confirms that:

I understand the information provided on this form and agree to the statements made above.
Intravenous (IV) Infusion Therapy, Intramuscular (IM), Micronutrient lab draw has been adequately explained to me by my provider.
I have received all the information and explanation I desire concerning the procedure.
I authorize and consent to the performance of Intravenous (IV) Infusion and Intramuscular (IM) Therapy.
I release San Antonio Prime Wellness and the medical staff form all liabilities for any complications or damages associated with my Intravenous (IV) Infusion, Intramuscular (IM) Therapy and Micronutrient lab draw.
I understand that this consent shall be in force and effect as long as I am a patient at this practice. I understand that I have the right to revoke this consent, in writing, at any time by sending such written notification to my provider(s) at this practice. However, the revocation will not have an effect on any actions taken prior to the date my revocation is received and processed.

Today's Date*

Date

Date of Birth*

Date

Name*

First NameLast Name

Signature - Your signature signifies your consents to the use and disclosure of your PHI by our office during treatment, billing, reimbursement, and medical office operations. You agree and consent that your PHI may be communicated to you via telephone or email (encrypted or unencrypted).*