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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)

I (the patient) understand that before IV Nutrition Therapy, I must:

  1. Complete lab work (CBC, Comp Metabolic Panel - optional).
  2. Notify the Provider of all medications and supplements you are currently taking, and current health issues you may be having.
  3. Arrive to IV Therapy appointment hydrated – if dehydration occurs because of the nutrient IV, you will be given fluids to correct the dehydration.
  4. Arrive to IV Therapy appointment having eaten a meal or snack, or bring snacks with you.

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.

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.

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.

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.

Your signature below means that:

  1. 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.
  2. The provider has adequately explained the IV procedure set forth to you.
  3. You have received all the information and explanation you desire concerning the procedure.
  4. You authorize and consent to the performance of the procedure as agreed upon with the Provider.
  5. 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 (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.

 

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