Form # 2, Please fill out - Family Medicine Practice

Nutrient Infusion Informed Consent

Date / Time

First Name

Last Name

Date of Birth

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I have informed the healthcare professional of any known allergies to drugs or other substances, or of any past reactions to anesthetics.

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I have informed the healthcare professional of all current medications and supplements.

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I, understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits.

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I understand that except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

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The procedure involves inserting a needle into a vein and injecting the prescribed solution and, alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.

I Understand the risks of intravenous therapy include but are not limited to:

a. Occasionally to commonly: Discomfort, bruising, and pain at the site of injection. A general feeling of warmth during and after injection

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b. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. Reactive Hypotension (or rapid drop in blood pressure). Reactive Hypoglycemia (or rapid drop in blood sugar)

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I Understand the risks of intravenous therapy include but are not limited to:

Benefits of intravenous therapy include:

Injectables are not affected by 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.

The Procedure

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.
Your vitals will be measured prior to and after your infusion.

I understand

My request for nutrient infusion therapy as described is entirely voluntary and I have not been offered any inducement to consent. I understand that I may refuse treatments at any time.

Final Statement of Patient Giving Informed Consent

BY SUBMITTING this form, I have read this consent form and understand the information contained in it.
I understand the risks and benefits and have had the opportunity to have all my questions answered to my satisfaction.
I am aware that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and or explain all risks and possible complications.
I rely on the provider(s) to exercise judgment during the course of treatment with regard 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.
My signature on this form affirms that I give my consent to IV nutrient therapy.

PATIENT Signature

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