IV Nutrition Infusion Therapy Consent Form
1. You have the right to be informed of the procedure, feasible alternatives, and the risks and benefits. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent.
a. The Procedure involves inserting a needle into your vein or muscle to inject the formula described by the doctor
b. Alternatives to intravenous therapy are oral supplementation and dietary and lifestyle changes
c. Risks of intravenous therapy include:
i. Discomfort, bruising and pain at the site of the injection
ii. Inflammation of the vein used for injection (phlebitis)
iii. Severe allergic reaction; anaphylaxis, cardiac arrest, death
d. Benefits of injection therapy include:
i. Injectables are not affected by stomach or intestinal disease
ii. Total amount of infusion is available to the tissues
iii. Nutrients are forced into cells by means of a high concentration gradient
iv. Higher doses of nutrients can be given than is possible by oral administration, without intestinal irritation
e. Contraindications to intravenous therapy include
i. Absolute contraindication: liver failure, renal failure, Addison’s disease, CHF
ii. Relative contraindications: Thallasemia, G6PD deficiency, decreased renal function, drug-nutrient interactions, allergy and/or sensitivity to substances intended for IV administration.
iii. Caution: HIV/AIDS, immune-suppression, post splenectomy, recent burns, malnourishment, chemotherapy
2. You have the right to consent to or refuse the proposed treatment at any time prior to its performance, Your signature on this form affirms that you have given your consent to the procedure described above along with any different or further procedures which, in the opinion of your Doctor, may be indicated.
3. The procedure will be performed by or under the direction of the Naturopathic doctor named below:
i. You understand the information provided on this form and agree to the foregoing.
ii. The procedure(s) set forth above has been adequately explained to you by the Doctor
iii. You have received all the information and explanation you desire concerning the procedure
iv. You authorize and consent to the performance of the procedure(s)
v. Following conditions do not exist in your current state of health and that you will immediately notify your practitioner of any changes regarding the following: liver failure, kidney failure, Addison’s disease, and congestive heart failure
vi. You have notified the doctor about your current status of relative and cautionary contraindications mentioned above and you will notify the practitioner immediately about any changes regarding the status of contradictions in the future.