This document is intended to serve as confirmation of informed consent for IV therapy.
I have informed the RN of all current medications and supplements. I have also informed Halo Med Spa of any known allergies to drugs or other substances, or of any past reactions to anesthetics.
I understand that I have the right to be informed of the procedure, any alternative options, and the risks and benefits of IV therapy. Procedures will not be performed until I have the opportunity to give my informed consent, except in the case of an emergency.
My signature below acknowledges that:
1. This procedure involves inserting a needle into the vein and injecting a prescribed solution.
2. Alternatives to IV therapy include, but are not limited to, oral supplementation.
3. The potential risks of IV therapy include, but are not limited to:
I. Occasionally: Discomfort, bruising and pain at the injection site.
II. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic
disturbances, and injury.
III. Extremely rarely: Severe allergic reaction, anaphylaxis, infection, cardiac
arrest, and death.
4. Benefits of IV therapy include:
I. Injectables are not affected by stomach, or intestinal absorption
II. The total amount of infusion is available to the tissues.
III. Nutrients are forced into cells by means of a high concentration gradient.
IV. Higher doses of nutrients can be given than is possible by oral consumption.
I am aware that unforeseeable complications could occur, and I do not expect Halo Med Spa RN's to anticipate or explain all possible complications.
I rely on the RN's to exercise judgement during the course of my treatment.
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 or refuse any proposed treatment at any time.
My signature affirms that I have given consent to IV therapy with Halo Med Spa.
I understand that all nutrient infusions are considered investigational/experimental and are not considered standard of care.
My signature below confirms that:
1. I understand the information provided on this form and consent to treatment.
2. The procedure(s) set forth above has been adequately explained.
3. I have received all the information and explanation I desire pertaining to the
4. I authorize and consent to the procedure(s).