Treatment Informed Consent and Waiver of Liability
I have requested that a healthcare professional under the supervision of the Medical Provider perform a procedure referred to as intravenous therapy or injection therapy. I understand that this procedure is an intravenous supplementation, not replacement, of fluids, nutrients, and/or medicines which are recommended but not guaranteed to:
• Maintain and enhance normal bodily functions
• Improve immune function
• Improve antioxidant status/Reduce oxidative damage through detoxification
• Improve fatigue
• Increase energy
• Improve athletic performance and/or recovery
• Improve proper hormone production
• Increase metabolism and assist with weight loss
• Optimize brain function/Increase mental focus
• Improve certain cardiovascular ailments
• Reduce histamine release improving allergy symptoms
• Improve gastrointestinal disorders
• Promote healing from injury/surgery/intense exercise or training
• Improve signs of aging
• Assist with symptom management (headaches, muscle cramps, gastrointestinal discomfort, pain)
• Reduce substance abuse withdrawal symptoms
• Decrease substance abuse addiction cravings
I understand that these treatment(s) each have a specific formula containing nutrients (vitamins, minerals, and amino acids), which are compounded in an FDA approved pharmacy and supplied by a third party supplier, and/or FDA approved medicines supplied by a third party supplier.
This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been indicated. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health.
| The procedure involves inserting a needle into a vein, placing a soft catheter, and infusing the elected therapy by a healthcare practitioner acting within their active state-regulated license/guidelines under the direction of a physician. |
| Benefits of intravenous therapy include but not limited to: • All of the above listed benefits related to my specific treatment • Absorption of these supplements and hydration is optimized as they bypass your gastrointestinal system, allowing for higher doses via direct delivery to all cells by means of a high concentration gradient. • Decreased gastrointestinal discomfort associated with orally ingesting high doses of supplements • Increased safety as these supplements are water-soluble, meaning whatever your body does not utilize is excreted by your kidneys |
| There are risks and side effects, although uncommon, to receiving intravenous therapy even when administered properly. While most side effects are rare, some may be experienced more commonly. This can vary from person to person due to current health and history. Some of these side effects can include but are not limited to: • Discomfort, burning/stinging sensation, and/or pain at the site of injection • Sense or feeling of being swollen over the entire body (bloating) • Changes in the appearance of skin and tissue at or around the insertion site (bruising) • Inflammation of the vein used for injection/phlebitis • Misplacement of the IV during insertion/infiltration • Bleeding at the insertion site • Scarring/injury at the insertion site, including but not limited to vein, nerve injury, and tissue necrosis • Gastrointestinal upset: nausea, vomiting, diarrhea, constipation, indigestion, heartburn • Metabolic disturbances Headache Allergic reactions (itching, hives, rash, swelling, difficulty breathing, wheezing, anaphylaxis) • Muscle spasms, weakness, fatigue, dizziness Infection, chills, fever • Cardiovascular disturbances: rapid heart rate, palpitations, chest pain, flushed face, vagal response • Cardiac arrest, air embolism, and death |
| I assume responsibility to seek immediate medical attention if any of the above side effects occur and are severe or are troublesome. |
| I have, to the best of my knowledge, in written form notified the Medical Provider of known allergies, current medications/supplements, all past and current medical conditions/diseases/disorders, as well as any other pertinent personal/health/social/lifestyle information in order to minimize complications. |
| I understand that certain medications/supplements whether natural, over-the-counter or prescribed, as well as known or unknown medical conditions, may increase my risk of the above side effects. |
| I deny having and am aware of contraindications for receiving the proposed treatment including but not limited to: congestive heart failure (CHF), fluid retention (ascites, edema, etc.) hemophilia, history of uncontrolled bleeding, kidney (renal) failure, kidney (renal) disease, Myasthenia Gravis, or pulmonary hypertension. |
| I am aware that other unforeseeable complications can occur. I do not expect the Medical Provider to anticipate and/or explain all risks and possible complications. I rely on the Medical Provider to exercise judgment during the course of treatment with regards to my procedure. I understand the procedure, the treatment, the risks and benefits of the procedure, have had the opportunity to have all of my questions answered, and have the right to refuse/stop treatment at any time. |
| I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. I understand that Mobile IV Medics performs appointment booking and related services and does not provide healthcare services. I understand that the procedure(s) will be performed by or on behalf of the Medical Provider who is solely responsible for reviewing my information and medical history. I release Mobile IV Medics from any and all liability associated with the performance of the procedure(s). |
| I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications, therefore may be considered medically unnecessary or not currently indicated. |
| I assume responsibility for informing all current and future healthcare provider(s) of my receiving the proposed treatment. I assume responsibility for discussing the appropriateness of my receiving the proposed treatment with my healthcare provider(s). |
| I hereby acknowledge that I understand that this procedure is not covered by my insurance. I agree to be personally and legally responsible for payment at the time of service for all services, including non covered services. |
| I further agree in the event of nonpayment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. |
| I understand my personal information will be kept private and protected in compliance with HIPAA, provided, however, that it will be shared between Mobile IV Medics and the Medical Provider. |
| I agree to have personal non-identifiable factors and my treatment information used or released by Mobile IV Medics and/or the Medical Provider for research purposes. However, under no circumstance will any personal information be disclosed by Mobile IV Medics with the exception of this Consent Form. |
Upon your authorization and consent, this intravenous and/or injection therapy will be performed on you by a Nurse Practitioner, RN, PA, or other provider as directed by the medical director of the Medical Provider. All invasive procedures carry the risk of unsuccessful results, complications such as rejection or infection, injury, or even death from both known and unforeseen causes, and no warranty or guarantee is made as to results or cure. You have the right to be informed of the nature of the procedure and it’s actual or potential risks, benefits, and side effects, as well as any reasonable alternative(s) including the right to do nothing, and the side effects of such alternative(s). You also have the right to give or refuse consent to any proposed procedure or therapy at any time prior to its performance. I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks, known and unknown.
I hereby give consent to the Medical Provider to perform this and all subsequent Intravenous Treatments with the above understood. I hereby release the Medical Provider, the healthcare practitioner performing the procedure on behalf of the Medical Provider, Mobile IV Medics, and third party suppliers from any and all liability related to the procedure.
