Informed Consent for Intravenous/Intramuscular Nutrient Therapy


I, the undersigning client , hereby authorize the following procedure: administration of intravenous vitamins, minerals, and other nutrients.The primary objective of my IV therapy is general health support. I am requesting the intravenous administration of vitamins and supplements. This procedure is recommended for replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, weight loss, improving fatigue, etc. I understand that intravenous vitamin and supplement therapy has not been approved by the FDA for treating any medical condition.

I expressly represent and warrant to iDrip Therapy (IDT AZ 1, LLC) that I have never been diagnosed with, nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in elective regimens, programs or services made available by iDrip Therapy (IDT AZ 1, LLC) and I am choosing not to participate with any expectation that iDrip Therapy (IDT AZ 1, LLC) will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.

This procedure may be considered medically unnecessary. It may or may not mitigate, or alleviate the complaint for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you seeked services and in your overall health.

The procedure involves inserting a needle into your vein or muscle and injecting the medicine/additives prescribed by the physician and medical director of iDrip Therapy (IDT AZ 1, LLC). You are being provided these services under the standing orders, protocols and Medical licensure of Dr. Ben Feinzimer.

I understand that participating in intravenous hydration (iv), vitamin/supplement administration, pharmaceutical administration, IM injections, programs and services made available by iDrip Therapy (IDT AZ 1, LLC) carries risks.

Risks and Side Effects:
The principal side effects and risks that may accompany intravenous/intramuscular administration of nutrients include:

-burning/stinging, bleeding, infection, inflammation/swelling, bruising and/or scarring at the site of infusion or if IV/IM infiltrates into surrounding tissue

-misplacement of IV lines in the body

-adverse reactions

-muscular spasms, weakness, or fatigue, nerve injuries, fluid overload

-light-headedness and/or fainting, allergic reactions (rare),

-air embolism (vary rare)

-local thrombophlebitis, anaphylaxis, cardiac arrest and death (very rare)

Based on the risks and potential benefits of the current medically indicated service(s) and of this proposed service, I have elected to forego or supplement the indicated service(s) and receive this proposed service from the health professionals at iDrip Therapy (IDT AZ 1, LLC) as is appropriate and necessary for my care.

Acknowledgement:

I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed service. 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. I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such regimen, programs and services rests entirely with me to the extent that I do not disclose my health conditions, medications or drug use in advance.

I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by iDrip Therapy (IDT AZ 1, LLC). I understand the nature of the sessions and programs and that participating in them carries risks. I have been informed that intravenous vitamin infusions are exceedingly safe, however some side effects can occur. The risks involved and the possibilities of complications have been explained to me. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction.

I've also been informed that the therapy may not have any beneficial effect. I fully understand and confirm that the nature and purpose of the aforementioned service to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated.

Client authorization is required for any disclosures of PHI (protected health information). A record of your services will be created regarding services that you have received. Federal and state law mandate that we must follow the Notice of Privacy practices that are in effect at the time of disclosure. We are committed to your privacy. Your PHI may be used in the following ways: Improvement of healthcare operations Advisement of additional services options health related benefits and services referral Dates of services, types of services, origin of information, age, gender, vital signs for QI Lawsuits/proceedings with a court or administrative order Response to discovery request, subpoena or other lawful process with notification of request Request by law enforcement official with sufficient warrant

I also verify that all information presented to medical providers 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 these elective services. I have fully disclosed my entire medical history including any prescription drugs and other supplements that I'm currently using. I understand that I should share with my other treating physicians the nature of my therapy. I have no kidney, liver, heart or other medical conditions to disclose that could be a barrier to receiving the infusion.

I hereby acknowledge that I understand that my therapy will not be insurance covered and non-reimbursable, and that I am responsible for the expense of therapy. I agree to be responsible for payment at the time of service for all services.

I expressly represent and warrant to activate that I am not a user of illegal drugs and/or controlled substances and currently am not under the influence of nor recovering from the use of illicit substances at the time of the provision of services to me.

By confirming this appointment and accepting this service(s), I acknowledge that I have read the foregoing informed consent and agree to the services with its associated risks. I hereby give consent to perform this service provided by iDrip Therapy (IDT AZ 1, LLC) and administered by its qualified staff.