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IV Therapy Consent Form
IV Therapy Consent Form
Read this form fully, fill it out, and submit before your IV.
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IV Therapy Consent Form
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  • English (US)
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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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    By signing, I understand that:

    1. The procedure involves inserting a needle into a vein and injecting the prescribed solution.
    2. Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.
    3. Risks of intravenous therapy including but not limited to:
      Occasionally to commonly: Discomfort, bruising, and pain at the site of injection.
      1. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
      2. Extremely Rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.
      3. 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:

    1. I understand the information provided on this form and agree to the foregoing.
    2. The procedure(s) set forth above has been adequately explained to me, by my physician.
    3. I have received all the information and explanation I desire concerning the procedure.
    4. I authorize and consent to the performance of the procedure(s).
    5. 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.
    6. I understand I am financially responsible for this procedure as this is a non-billable service.
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