Informed Consent for Intravenous (IV) Therapy & Chelation This document is intended to serve as confirmation of informed consent for IV therapy and/or chelation as ordered by Robinhood Integrative Health.
I understand that I have the right to be informed during the procedure, 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.
The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids) or chelation agents. Chelating agents may be infused for pre-treatment testing. Chelation testing helps your physician to develop a chelation treatment plan.
I understand that risks, benefits, and alternatives to IVs or IV/Oral chelation may include but are not limited to:
1. The Risks and potential side effects
○ Discomfort, bruising, and pain at the site of injection.
○ Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
○ Severe reaction, anaphylaxis, cardiac arrest, or death.
2. The Benefits
○ Injectables are not affected by stomach or intestinal disease.
○ Total amount of infusion enters the bloodstream and is available to the tissues
○ Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth.
○ IV chelation therapy helps to reduce and eliminate heavy metals.
3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes. Alternative therapies to intravenous chelation are oral chelation therapy or therapies to improve the natural elimination of metal compounds through nutritional supplementation and tissue cleansing such as constitutional hydrotherapy and colon hydrotherapy.
I am aware that other unforeseeable complications could occur. I do not except the physician(s) to exercise judgment during treatment with regards to my procedure. I understand the risks and benefits of the procedure 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 form affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures) set forth above have been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of the amount used due to wasted materials.
My signature below confirms that:
1. I have received all the information and explanation I desire concerning the procedure.
2. I authorize and consent to the performance of the procedure(s)