I AM IV Drips

Special Instructions

Intravenous Therapies I give 1111 Rejuvenation Wellness and SlimTone as well as the Staff at this office, permission to perform single or recurring Intravenous Therapy (“NT”). I am executing this consent to confirm my understanding of the risks, benefits, and alternatives to treatment with Intravenous Therapy.   Intravenous (IV) therapy as used in this ofce is a means to deliver nutrient substances, and other medications, to your body while avoiding the digestive process. This is helpful in many cases where patients are depleted of certain nutrients, or when the substance can have more medicinal value through the IV route. This procedure is recommended for replacement of these essential nutrients, correction of deciencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, decreasing bronchospasm, improving fatigue, etc.   It is important for you to understand that this type of therapy, although common, is considered by some physicians to be unconventional and not the standard of medical care for most conditions. Our professional experience with this type of therapy allows us to offer it for your condition as a viable alternative or addition to other (more standard) medical treatments.   Most patients have no adverse effects from the type of IV therapy we offer. Some common effects that may come and go but are generally safe MAY be: A warm / tired or relaxed feeling from the minerals in the IV Slight to moderate light headedness Short term blood sugar changes Discomfort, such as burning and stinging, at the IV site during or after the treatment Thirst Nausea These effects are best dealt with as they arise, and we will give you specic instructions to help avoid or shorten them. It is your responsibility to inform us immediately if you feel any discomfort or sensation that is unusual.   Inltration of the IV (the uid leaking out of the vein and into the surrounding tissues) is an occasional occurrence in all IV therapy. It can cause pain, swelling, and bruising on occasion. This is rare in our ofce practice as the IV time is relatively short (as compared with IV duration in the hospital setting). If this occurs we will treat it as necessary. The effects of inltration can be uncomfortable, but do go away. If you notice pain, swelling or bruising around your IV site please let us know. Immediately apply ice as well.   Similarly to inltration, the vein may become sore or slightly swollen or warm after an IV. This is typically irritating but not dangerous, and the vein may feel rm for one to ve weeks. Notify us of this immediately as well.   Although materials injected in this clinic are generally safe and well tolerated by the body it is important for you to understand that all injections may cause very rare but potentially serious or even life threatening reactions. We will and do take necessary precautions to avoid serious complications – but you need to know that they exist, however rare the risk may be.   I understand that my treatment records and test results may be used as the basis for a published study and consent to such use of my treatment results. I further understand and agree to adhere to the treatment schedule and attend the follow-up visitations set by my medical provider to permit observation and study of my progress. I understand that I may suspend or terminate my treatment at any time by informing my medical provider. 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. The risks involved and the possibilities of complications have been explained to me. I fully understand and conrm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientic testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated.   I hereby place myself under your care for intravenous vitamin therapy, and agree to the above release. I also verify that all information presented to medical provider in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment for these conditions.   I hereby acknowledge that I understand that my Insurance coverage, including Medicare, may not pay for this Non-covered service, and that all services ancillary to this treatment may be also Non-covered services and Non-reimbursable. I agree to be responsible for payment at the time of service for all services, including Non-covered services.