Consent for lipotropic amino acid, complex vitamin and nutrient therapy
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This document is intended to serve as confirmation of informed consent for injection therapy such as ordered by Balance Wellness Center under the care of Dr. Ronald Bryant. I have informed Dr. Bryant and Balance Wellness Center staff of any known allergies to drugs or other substances, or of any past reactions to injections. I have informed the doctor of all my medical conditions and current medications. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. I understand that: The procedure involves inserting a needle into various areas of the body and injecting of vitamins and other homeopathic remedies. Risks of injection therapies include but are not limited to: Occasionally to commonly: Pain, bruising, inflammation, injury and numbness at the site of injection. Fatigue, dizziness, or light-head feeling after the injections. Fainting or loss of consciousness during the procedure. Extremely rare: Severe allergic reaction, anaphylaxis, infection. I am aware that other unforeseeable complications could occur. I do not expect the physician to anticipate and or explain all risk and possible complications. I rely on the physician and staff to exercise judgment during the course of treatment with regard to any procedure. 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 to 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 injection therapy with any different or further procedures which may be indicated. My signature below confirms that: I understand the information provided on this form and agree to the foregoing. The procedure(s) set forth above has been adequately explained to me I have received all the information and explanation I desire concerning the procedure. I authorize and consent to the performance of the procedure(s).
I understand and agree to treatment.
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