IV Therapy Consent Form

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This document is intended to serve as confirmation of informed consent for IV therapy as ordered by the physician at Institute of Complementary Medicine.
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Check the boxes once you have alerted your doctor of any of the following:* This field is required.
I have informed the physician of any known allergies to drugs or other substances, or of any past reactions to anesthetics.
I have informed the doctor of all current medications and supplements.
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 I may be financially responsible for this procedure, as compounded nutrients are not billable to insurance companies.
I am aware that other unforeseeable complications could occur. I do not expect the physician(s) to anticipate and or explain all risks and possible complications. I rely on the physician(s) to exercise judgment during the course of treatment with regards to my 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.
I understand my signature on this form affirms that I have given my consent to IV therapy with any different or further procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.
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By signing, I understand that:

The procedure involves inserting a needle into a vein and injecting the prescribed solution.

Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.

Risks of intravenous therapy including but not limited to:
Occasionally to commonly: Discomfort, bruising, and pain at the site of injection.

Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

Extremely Rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.

Benefits of intravenous therapy include:
injectables are not affected by the stomach or intestinal absorption problems.
The total amount of infusion is available to the tissues.
Nutrients are forced into cells by means of a high concentration gradient.
Higher doses of nutrients can be given than possible by mouth without intestinal irritation.
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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, by my physician.

I have received all the information and explanation I desire concerning the procedure.

I authorize and consent to the performance of the procedure(s).

The cost of IV ingredients can fluctuate, ICM tracks this regularly and will adjust costs accordingly. As a result, the cost of your IV may change from the previous IV administered. If a drastic increase happens, ICM will do our best to inform patients of this increase prior to your IV treatment.

I understand I am financially responsible for this procedure as this is a non-billable service.
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My initials signify I have read an understand everything on this form and I have informed my doctor of any complaints or concerns prior to starting the IV Treatment.* This field is required.
Initials
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Name* This field is required.
First Name
Last Name
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Signature* This field is required.
Clear
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Date signed:* This field is required.
Date
Month
Day
Year
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