IV/IM Consent Form

I consent to the insertion of a peripheral intravenous/intramuscular catheter/needle and to the infusion/injection of fluids, vitamins, mineral and/or compounded cofactor, and/or medications. I agree and acknowledge that no promises or guarantees were made regarding the efficacy of the infusion/injeciton. Further, I acknowledge that statements regarding vitamin and mineral infusions/injections have not been evaluated by the FDA and that the infusion/injection of such has no diagnostic value nor is the infusion a substitute, cure, therapy, or treatment for any disease or condition.

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I understand that the infusion/injection is being carried out under the direction of Benjamin Feinzimer, DO and/or Leo Treysman, MD, and/or Ricardo Santayana, MD (Medical Directors) and by a non- physician who is trained in the safe insertion, monitoring, stabilization, and removal of intravenous/intramuscular catheters/needles and infusions/injections. If at any time, a determination is made that the procedure or infusion is outside of the conditions of safety, it may be discontinued.

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I understand the benefits of IV/IM infusions/injections may be limited if I am an active smoker, live a sedentary lifestyle, and/or have a diet that contains an excess of calories and/or a deficiency of nutrients. I understand that I may be asked to take oral supplements between treatments and a failure to take these supplements may reduce the benefits of the IV/IM therapy and may even create unwanted effects of the IV/IM therapy.

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I understand that a series of infusions/injections may be anticipated. I understand that infusion(s)/injection(s) may need to be repeated in the future in order to maintain the benefits.

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IV ACCESS RISK

Intravenous or "IV" access has infrequent but important risks. The following is a description and techniques used to mitigate those risks:

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POTENTIAL COMPLICATIONS

1. Infiltration - delivery of medication or fluids around the blood vessel; infiltration may cause swelling and inflammation, is typically harmless and will commonly resolve within several days.

2. Hematoma - bruising due to bleeding from the punctured vessel, may include mild pain and swelling, and typically resolves within 1-2 weeks.

3. Air Embolism - rare complication when air > 1mL/kg of body weight is introduced into the vein, may be life-threatening and may require emergency attention.

4. Phlebitis and Thrombophlebitis - inflammation in and around the punctured vein, becomes more common in frequent IV users; iDrip limits vein puncture to a maximum of once every two weeks; for requests of greater frequency Drip requires either special approval from your personal healthcare provider or following discussion with an iDrip medical director.

5. Micro clots - tiny blood clots associated with high frequency vein puncture; typically treated with heat compresses, NSAIDs (e.g., ibuprofen), and elevation of the limb.

6. Intraarterial injection - inadvertent puncture of an artery instead of vein; may result in spasm of the artery and injury to the limb; medical attention may be required.
    

My agreement and further scheduling of services in this site indicates understanding and acceptance of these risks.

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PAYMENT

Payment is due at the time of service. There has been no representation that this procedure is covered under my insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless if the infusion/injections cancelled or is stopped at any time prior to completion at the discretion of the technician/nurse/clinical assistant or myself.

I understand that I am responsible for the full cost of the procedure and agree to pay.

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The procedure(s) and this consent form have been adequately explained to me. I agree that, at the time of service I will not intoxicated on alcohol or any illicit drugs, and I authorize and consent to the performance of the procedure(s).

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