Informed Consent For Intravenous (IV) Therapy & Chelation
This document is intended to serve as confirmation of informed consent for IV therapy and/or chelation as
ordered by Integrative Health.
Name
Email
Phone
I have informed the physician of any known allergies to drugs or other substances that maybe included in the ingredients of my solutions, or of any past reactions to anesthetics.
I have informed the doctor of all current medications and supplements.
I understand that I have the right to be informed during the procedure, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.
The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined periodof time, prescribed nutrients (vitamins, minerals, amino acids) or chelation agents. Chelating agents may beinfused for pretreatment testing. Chelation testing helps your physician to develop a chelation treatmentplan.
I understand that risks of IVs or IV/Oral chelation may include but are not limited to: Discomfort, bruising, and pain at the site of injection; Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury; Severe reaction, anaphylaxis, cardiac arrest, or death.
I understand that benefits of IVs or IV/Oral chelation are not affected by stomach or intestinal disease; The total amount of infusion enters the bloodstream and is available to the tissues; Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth; IV chelation therapy helps to reduce and eliminate heavy metals.
I understand that alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes. Alternative therapies to intravenous chelation are oral chelation therapy or therapies to improve the natural elimination of metal compounds through nutritional supplementation and tissue cleansing such as constitutional hydrotherapy and colon hydrotherapy.
I am aware that other unforeseeable complications could occur. I do not except the physician(s) to exercise judgement during the course of treatment with regards 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. Checking this box affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures) set forth above has been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials.
My signature below confirms that: 1. I have received all the information and explanation I desire concerning the procedure. 2. I authorize and consent to the performance of the procedure(s)
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