Informed Consent to IV Nutrient Therapy

The purpose of this informed consent form is for your Drip Hydration provider to give you written information regarding the risks, benefits, and alternatives of Intravenous Nutrient Therapy (IV Therapy). This material serves as a supplement to the discussion you have with your provider about the treatment. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your provider prior to signing the consent form.

IV Nutrient Therapy Procedure: Intravenous (IV) Nutrient therapy is means to deliver nutrient substances, and other medications, to your body while avoiding the digestive process. This is helpful in many cases where patients are depleted of certain nutrients, or when the substance can have more medicinal value through the IV route.

The IV Therapy procedure is performed by licensed healthcare professionals of Drip Hydration and involves inserting a needle into the vein and infusing or injecting a solution of nutrients (vitamins, minerals, amino acids, glutathione, electrolytes, sugars, and diluents) over a period of time.

Potential Benefits of IV Therapy depend on the substance(s) being infused. Such benefits include but are not limited to:

• Nutrients infused into the bloodstream are not affected by stomach or intestinal absorption disturbances and therefore is better absorbed by the body. This can be especially helpful for individuals with conditions such as decreased intestinal absorption of nutrients, achlorhydria, long-term PPI use, and pernicious anemia. 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.

Most patients have no adverse effects from the type of IV therapy we offer. However, some more common potential side effects include:

• A warm / tired or relaxed feeling from the minerals in the IV
• Temporary metabolic disturbances such as temporary changes in blood sugar, temporary changes in blood pressure leading to lightheadedness or dizziness and/or increased thirst
• Discomfort such as pain, redness, bruising, swelling, burning, stinging, bleeding and/or scar formation at the IV site during or after treatment.

These effects are best dealt with as they arise, and we will give you specific instructions to help avoid or shorten them. It is your responsibility to inform your Drip Hydration provider immediately if you feel any discomfort or sensation that is unusual.

Other potential risks include:

• Infection is always a potential risk when the skin is punctured even when sterile procedures are used.
• Infiltration of the IV (the fluid leaking out of the vein and into the surrounding tissues) is an occasional occurrence in all IV therapy. It can cause pain, swelling, and bruising on occasion. This is rare in our office practice as the IV time is relatively short (as compared with IV duration in the hospital setting). If this occurs, we will treat it as necessary. The effects of infiltration can be uncomfortable, but do go away. If you notice pain, swelling or bruising around your IV site please let us know immediately.
• Similarly to infiltration, the vein may become sore or slightly swollen or warm after an IV. This is typically irritating but not dangerous, and the vein may feel firm for one to five weeks. Notify us of this immediately as well.
• Although materials injected in this clinic are generally safe and well tolerated by the body it is important for you to understand that all injections may cause very rare but potentially serious or even life threatening allergic reactions. We will and do take necessary precautions to avoid serious complications – but you need to know that they exist, however rare the risk may be.

Potential Alternatives of IV Therapy include but are not limited to: No treatment; Oral supplementation of nutrients; Transdermal application of certain substances such as B12 patches, and Dietary and lifestyle changes.

Contraindications depending on IV Therapy solution, may include but are not limited to: Liver and/or kidney dysfunction; heart disease; G6PD Deficiency; Pregnancy and breastfeeding. Please tell your provider immediately if you are pregnant or are breastfeeding.

By signing this form you acknowledge that you understand and agree to the following:

I am aware that unforeseeable complications could occur, and I do not expect my Drip Hydration provider to anticipate all possible complications. Additionally, I understand that any possible side effects from IV Therapy are best dealt with as they arise, and that it is my responsibility to inform my provider immediately if I feel any discomfort or sensation that is unusual.

No Guarantees: I understand that each patient responds differently to treatments and from one treatment to the next. I understand results are only temporary and the length of time IV Therapy is needed for therapeutic benefit varies for each patient. There is no guarantee, implied or stated, that the IV Therapy administered will improve, reduce or eliminate any medical symptoms or conditions.

I understand that the nature and purpose of IV Therapy may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered by some physicians to be medically unnecessary and not the standard of medical care for most conditions. Additionally, I understand and acknowledge that the United States Food and Drug Administration (FDA) has not evaluated or approved IV Therapy to diagnose, treat, cure, or prevent any disease.

Complete Medical Information: I understand that IV Therapy may be contraindicated if I have certain medical conditions, allergies and/or take certain medications. I have truthfully 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. I understand that failure to do so may negatively affect my treatment outcome and the safety of the IV Therapy and there shall be no liability on Drip Hydration or a Drip Hydration provider’s part if I fail to do so.

Pregnancy and Breastfeeding: I am not pregnant or breastfeeding and agree to notify my Drip Hydration provider if I become pregnant prior to any further treatments.

CERTIFICATION OF CONSENT TO PROCEED WITH TREATMENT: By signing this Informed Consent to Intravenous Therapy, I confirm and agree that: I have read this entire Informed Consent, and I understand and agree to the information herein. The nature of the therapy, and the potential risks, benefits and alternatives have been explained to me, and I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I hereby freely and voluntarily accept all risks associated with IV Therapy and elect and consent to proceed with treatment with Drip Hydration, and I intend this consent to remain in effect for my future IV Therapy treatments with Drip Hydration.