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.

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.

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.

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.

IV ACCESS RISK

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

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.

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.

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).