Informed Consent to Intravenous Hydration and Nutrient Therapy Roland Sorrentino June 7, 2024

Informed Consent to Intravenous Hydration and Nutrient Therapy

The purpose of this Informed Consent to Intravenous Hydration and Nutrient Therapy (IV Therapy) is to obtain your consent to the IV Therapy services ordered by your provider, The Good Life and IV Therapy, LLC. It is intended to document that you have been informed about the benefits and risks of the IV Therapy as well as the availability of alternatives, that you have had a chance to ask questions about IV Therapy, and that you voluntarily consent to the following treatments.

IV THERAPY PROCEDURE

  • The IV Therapy procedure involves inserting a needle into the vein and infusing or injecting a solution of nutrients (i.e., vitamins, minerals, amino acids, glutathione, electrolytes, sugars, and diluents) over time.
  • IV Therapy is a means to deliver vitamins, minerals and other nutrients to the body while avoiding the digestive process.
  • IV Therapy may reduce fatigue, boost muscle recovery and energy, and possibly improve cellular function and repair to slow aging.
  • Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease.
  • These IV infusions are not a substitute for your routine primary medical care.

POTENTIAL BENEFITS AND ALTERNATIVES OF IV THERAPY

  • Benefits may include more energy, hydration, reduced muscle aches, enhanced relaxation, and better sleep.
  • Nutrients infused into the bloodstream are not affected by stomach or intestinal absorption disturbances.
  • Higher doses of vitamins, minerals and other substances can be given than is possible by oral consumption and without intestinal irritation that can accompany doses given by mouth.
  • Alternatives to IV Therapy include taking oral supplements or not doing any treatment.

POTENTIAL SIDE EFFECTS AND RISKS OF IV THERAPY

  • • Discomfort such as redness, bruising, swelling, burning, stinging, pain, and/or bleeding at the site of the infusion. The redness and swelling may last up to a few days.
  • Inflammation, soreness and/or swelling of the vein used for the IV Therapy infusion, including phlebitis.
  • Temporary metabolic disturbances such as temporary changes in blood sugar, temporary changes in blood pressure leading to lightheadedness or dizziness and/or increased thirst.
  • Infiltration or leaking of the IV Therapy solution into surrounding tissue.
  • Infection at the site of the infusion.
  • Injury to nerve and/or muscle at the site of the infusion.
  • Sensitivities or allergic reactions to the IV Therapy solution which could include, as any allergic reaction, anaphylaxis, cardiac arrest, and death.
  • I am aware that other unforeseeable complications could occur. I do not expect the nurse or physician to anticipate and or explain all the risks and possible complications.
  • I will immediately take myself to a hospital if I am feeling very unwell after the injection.

INFUSING TORADOL AND ZOFRAN

  • If infused, Toradol may help with body aches, headache, or fever. The alternatives to Toradol are no intervention, over the counter ibuprofen or acetaminophen. The risks of Toradol are allergic, anaphylaxis.
  • If infused, Zofran may help with nausea. The alternatives to Zofran are no intervention and drinking water. The risks of Zofran are prolonged QT syndrome or constipation.

DO NOT USE IV THERAPY AND IMMEDIATELY INFORM YOUR PROVIDER IF YOU HAVE ANY OF THE FOLLOWING CONDITIONS

  • Known liver and/or kidney dysfunction.
  • High blood pressure.
  • Known heart disease.
  • G6PD Deficiency.
  • Pregnancy.
  • Problems with IV hydration therapy in the past.

COMPLETE MEDICAL INFORMATION

  • I understand that IV Therapy may be harmful if I have certain medical conditions, allergies and/or take certain medications.
  • I have truthfully, fully, and accurately disclosed all personal medical information including but not limited to all of my health conditions, my use of all medications, herbs, vitamins, and other supplements, and all known allergies to drugs or other substances or any past reactions. I understand that failure to do so may negatively affect my treatment outcome and the safety of the IV Therapy.

NOTICE TO ALL FEMALE PATIENTS

  • I certify that I am not currently pregnant.

NO GUARANTEES:

I understand that each patient responds differently to treatments and from one treatment to the next. I further understand that no guarantee can be made or is made by The Good Life and IV Therapy, LLC with respect to results or length of time required for IV Therapy benefit. EMERGENCY OR OTHER MEDICAL TREATMENT. In the unlikely and rare event that your The Good Life and IV Therapy, LLC provider feels you require emergency medical services or other services that The Good Life and IV Therapy, LLC cannot provide (for example, a higher level of services), your provider may arrange for your transfer to a hospital or other medical provider, including by calling 911. In such an event, all costs for the emergency or follow up medical services provided to you by the hospital, ambulance company, and/or other provider will be your sole responsibility.

By signing the Informed Consent for Intravenous Hydration and Nutrient Therapy, Client confirms and agrees that:

I have read this entire Informed Consent, or someone has read it to me, and I understand and agree to the information on this form and to the following.

  • The nature of the IV Therapy and the potential risks, benefits and alternatives have been explained to me, and I have had the opportunity to ask questions about the procedure and all my questions have been answered to my satisfaction.
  • No outcomes or results of IV Therapy have been promised or guaranteed.
  • All the information that I have provided to my health care provider is complete, true and accurate to the best of my knowledge.
  • I understand that this treatment may involve risks and complications as explained in this consent, and I hereby voluntarily accept all risks associated with IV Therapy and elect to proceed with treatment. Further, to the fullest extent allowed by law, I hereby voluntarily waive, release, discharge, and agree to indemnify and hold harmless The Good Life and IV Therapy, LLC, including its members, officers, employees, volunteers, contractors, insurers, and agents (together the “Released Parties”), from any and all claims, demands, actions, injuries, causes of action, costs, losses, damages, expenses, and liabilities (whether by me my estate, my heirs, my assigns, or by third parties) that I may incur while visiting a Good Life and IV Therapy, LLC treatment, while having treatment in my home, or result from or arise out of the IV Therapy, including (without limitation) those relating to the risks described in this consent form and/or caused by the negligence of The Good Life and IV Therapy, LLC or any Released Party. See “Potential Side Effects and Risks of IV Therapy” and “Infusing Toradol and Zofran” for a description of the risks of IV Therapy.
  • I hereby give my informed consent to participate in IV Therapy to The Good Life and IV Therapy, LLC.