CONSENT AND AUTHORIZATION FOR INTRAVENOUS THERAPY PROCEDURES

MULTI VITAMIN MINERAL THERAPY

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

IV Therapy

provides facilities and personnel to assist in the performance of intravenous therapy. You have the right to be informed of the procedure, any feasible alternative options, the risks and benefits. Alternatives to intravenous therapy is oral supplementation and/or dietary and lifestyle changes. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent. does not claim any clinical therapeutic outcomes, and results may vary from every individual patient.

The procedure involves inserting a needle into your vein or muscle and injecting the formula prescribed by your physician. It will be performed by or under the direction of your physician with qualified healthcare providers.

Benefits of intravenous therapy include:
• Injectable are not affected by stomach or intestinal disease.
• Total amount of infusion is available to the tissues.
• Nutrients are focused into cells by means of a high concentration gradient.
• Higher doses of nutrients can be given than possible by mouth, without intestinal irritation.

Risks of intravenous therapy include:
• Potential risks of pain, discomfort, bruising, infection, or inflammation of the vein/phlebitis at or near the injection site.
• Severe allergic reaction.

Serious potential side effects could occur in the following patients:
• A genetic defect called “Glucose 6 Phosphate ‐ ‐ Dehydrogenase Deficiency”, or G6PD‐‐ deficiency, also known as “Favism”.
• Patients with Chronic Renal Insufficiency, or decreased kidney function
• Patients with Congestive Heart Failure and/or Atrial Fibrillation “A fib” ‐‐
• Patients with very Low Blood Pressure, readings lower than 90 mm Hg systolic or 60 mm Hg diastolic (esp. Magnesium containing IV Infusions)
• Patients taking Digoxin or other Potassium depleting ‐‐ drugs, diuretics, beta agonists, ‐ or glucocorticoids; If patient is hypokalemic (esp. Magnesium containing IV Infusions)
• Unknown allergies

Pregnant Women You have the right to consent to or refuse any proposed treatment at any time prior to its performance.

Your signature below AFFIRMS that:
You understand the information provided on this form and agree to the foregoing.
The procedure(s) set forth above has been adequately explained to you by your physician. You have received all the information and explanation you desire concerning the procedure. You authorize and consent to the performance of the procedure(s).

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :