IV Therapy Consent IV Nutrition Therapy is a powerful way to access cells, to accelerate healing, and prevent infection. While the use of IV nutrients is safe, is some cases there can be issues and complications. You 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 you have had an opportunity to receive such information and to give your informed consent. By following our recommendations below, we can minimize the complications and risks and ask that you follow the guidelines for IV Therapy treatment. Patient Name(Required) First Last Email(Required) Enter Email Confirm Email I (the patient) understand that before IV Nutrition Therapy, I must: Complete lab work (CBC, Comp Metabolic Panel - optional). Notify the Provider of all medications and supplements you are currently taking, and current health issues you may be having. Arrive to IV Therapy appointment hydrated – if dehydration occurs because of the nutrient IV, you will be given fluids to correct the dehydration. Arrive to IV Therapy appointment having eaten a meal or snack, or bring snacks with you. Initials(Required) I (the patient) understand that the following will reduce the efficacy of IV Nutrition Therapy and that it may take more treatments to reach optimal health: Cigarette Smoking. Certain medications. Caffeine consumption increases Vitamin C excretion. Poor diet: processed foods, high sugar intake, nutrient deficient diets. Heavy metal toxicity. Initials(Required)I (the patient) understand that having an IV Nutrition Therapy may stimulate the immune system and detoxification pathways and this can cause symptoms such as fever, fatigue, headaches, and nausea. Please contact us if you have concerns or questions following your IV Therapy treatment.Initials(Required) I (the patient) understand the Risks of IV Therapy include: Possible fall in blood pressure which can be related to magnesium in the IV. The provider will be present and able to help you by stopping the infusion and/or providing some extra IV fluids to bring the blood pressure to normal. Discomfort, bruising and pain at the site of injection. Inflammation, bleeding, infiltration or infection of the vein used for injection, phlebitis. Severe allergic reaction, anaphylaxis, cardiac arrest and death. Initials(Required) I (the patient) understand that IV Nutrition Therapy is not covered by insurance and that IV Therapy Houston will not bill my insurance for this service. I (the patient) understand that if I submit an insurance claim for the IV Nutrition Therapy, that I will be responsible for any and all non-covered services.Initials(Required) Your signature below means that: You have read and understand the information provided in this form, had all your questions answered, are knowledgeable about the conventional treatments available for your condition, and are aware that the IV Nutrition Therapy is not FDA approved and is considered “unconventional”. Long-term adverse consequences of these therapies may be possible, but are unknown at this time. By signing this consent, and agree to the foregoing. The provider has adequately explained the IV procedure set forth to you. You have received all the information and explanation you desire concerning the procedure. You authorize and consent to the performance of the procedure as agreed upon with the Provider. You understand that there are no refunds to IV Treatment once the treatment is started. By signing this consent, I understand these risks, and I am willing to accept the risk. I have been advised that this therapy may be beneficial in my condition. I understand the benefits of this treatment will be enhanced by engaging in positive lifestyle changes such as exercise, proper diet, and nutritional supplementation that has been recommended by the Healthcare Provider. I (the patient), give my informed consent for Intravenous Therapy to IV Therapy Houston (Houston Medical Wellness Clinic) and Dr. Robert Casimir DO & his designated staff. I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND ALL MY QUESTIONS HAVE BEEN ANSWERED. I understand I should not sign this form if Intravenous Vitamin Supplementation Therapy, its possible risks, and its possible benefits have not been explained to my satisfaction. I further understand that I should not sign this form if I have unanswered questions or if I do not understand anything in the consent form. Legal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically. I (the patient), give my informed consent for Intravenous Therapy to IV Therapy Houston (Houston Medical Wellness Clinic) and Dr. Wesley Nahm MD & his designated staff. I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND ALL MY QUESTIONS HAVE BEEN ANSWERED. I understand I should not sign this form if Intravenous Vitamin Supplementation Therapy, its possible risks, and its possible benefits have not been explained to my satisfaction. I further understand that I should not sign this form if I have unanswered questions or if I do not understand anything in the consent form. Patient Signature(Required)CAPTCHAThis field is hidden when viewing the formWitness Email This field is hidden when viewing the formWitness Name First Last This field is hidden when viewing the formWitness Signature
