Informed Consent For Intravenous (IV) Therapy & Chelation
This document is intended to serve as confirmation of informed consent for IV therapy and/or chelation as ordered by Integrative Health.
I have informed the physician of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics.
Initials:
I have informed the doctor of all current medications and supplements.
Initials:
I understand that I have the right to be informed during the procedure, of the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.
The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids). Chelating agents may be infused for pretreatment testing.
I understand that risks and benefits to IVs may include but are not limited to:
1. The Risks and potential side effects
- Discomfort, bruising, and pain at the site of injection.
- Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury
- Severe reaction, anaphylaxis, cardiac arrest, or death.
2. The Benefits
- Injectable’s are not affected by stomach or intestinal disease.
- Total amount of infusion enters the bloodstream and is available to the tissues
- Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth.
I am aware that other unforeseeable complications could occur. I except the physician(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated. I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above has been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that I will incur the full fee for treatment.
I, the signer, hereby grant and authorize Revive Room LLC (DBA Intra|V) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures and/or video taken of me by Revive Room LLC (DBA Intra|V) to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, banners, brochures, advertisements, websites, social media networking sites and other print and digital communications, without payment or any other considerations. This authorization extends to all languages, media, formats, and markets now known or hereafter devised. This authorization shall continue indefinitely unless I otherwise revoke said authorization in writing.
I understand and agree that these materials shall become the property of Revive Room LLC (DBA Intra|V) and will not be returned.
I hereby hold harmless and release Revive Room LLC (DBA Intra|V) from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.
I warrant that I am of the age of consent (18 years or older) and that I am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
If you are the parent or guardian, signing on behalf of person or persons under the age of consent, by signing, you certify that you are the parent or guardian and do hereby give your consent without reservation to the foregoing on behalf of the individual.
This document is intended to serve as a confirmation of informed consent for compounded Semaglutide, which is a prescription weight management medication.
A. Patient Informed Consent
1. I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
2. I have the right to be informed of any alternative options, side effects, and the risks and benefits.
3. I understand the mechanism of action of the medication.
4. I understand how it is to be administered.
5. I understand the prescription may come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
6. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
7. I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.
Common side effects include, but are not limited to:
· Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase
· Neurological: Headache, dizziness
· Cardiac: Heart rate increase, Hypotension
· Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
· Ophthalmic: Retinal disorder (diabetic patients)
· Skin: redness or pain at injection site
Serious Reactions include, but are not limited to:
· Thyroid C-cell tumor (animal studies)
· Medullary thyroid cancer
· Hypersensitivity reaction
· Anaphylaxis
· Angioedema
· Acute kidney injury
· Chronic renal failure exacerbation
· Pancreatitis
· Cholelithiasis
· Cholecystitis
· Syncope
Do not take this medication if:
· You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer). Multiple Endocrine Neoplasia syndrome type 2.
· You are pregnant or plan to become pregnant while taking this medicine.
· You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist. Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.
· You have a history of Pancreatitis.
· You are allergic to NAD+, Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®; If you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems.
Possible drug interactions:
Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® (THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.
B. I understand that I have the following responsibilities:
1. I agree to obtain prescriptions for compounded semaglutide only from The Revive Room LLC, DBA Intra-V
2. Medical history: I will inform The Revive Room LLC, DBA Intra-V of my complete medical history, including: allergies, medications, medical/surgical/social/family history.
a. I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.
b. I will be honest to the best of my ability the history she needs to know.
c. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
d. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider
e. I will always tell other providers about all medications I am taking.
f. The Revive Room LLC DBA Intra-V may ask for me to seek additional labs while on treatment to ensure it’s safety.
3. Discontinuation of medication: I understand that The Revive Room LLC, DBA Intra-V may stop prescribing my medications if:
a. I am having unfavorable side effects or it’s not working to treat my medical condition
b. I have been untruthful in my medical or family history
c. I do not follow through with the recommended plan of care set by The Revive Room LLC DBA Intra-V.
d. I do not follow any parts of “Part B: responsibilities” in this agreement.
I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.
WAIVER AND RELEASE OF LIABILITY FOR RED LIGHT THERAPY BED
I understand that the use of the Red Light Therapy Bed at Intra-V may involve risks, including but not limited to temporary skin irritation, burns, photosensitivity reactions, or eye damage if appropriate precautions are not followed. I acknowledge these risks and choose to voluntarily participate in red light therapy sessions.
I understand that red light therapy is not intended to diagnose, treat, cure, or prevent any medical condition. I acknowledge that it is my responsibility to consult with my healthcare provider before using the red light therapy bed, particularly if I have any pre-existing medical conditions, am pregnant, am sensitive to light, or am taking medications that may increase light sensitivity.
I acknowledge that results from red light therapy vary from person to person and that Intra-V makes no specific promises regarding the outcome of this treatment for my particular condition or purpose.
I agree to use protective eyewear provided during each red light therapy session to protect my eyes from potential harm.
In consideration of being allowed to use the red light therapy bed at Intra-V, I hereby release, discharge, and hold harmless Intra-V, its owners, staff, employees, agents, and representatives from any and all liability, claims, demands, actions, or causes of action arising from any injury, loss, or damage sustained during or as a result of my use of the red light therapy bed, whether caused by negligence or otherwise. I agree to indemnify and hold harmless Intra-V, its owners, employees, and agents from any claims, damages, liabilities, costs, and expenses, including legal fees, arising out of or related to my use of the red light therapy bed.
I confirm that I have received sufficient information regarding the nature of red light therapy, its potential benefits, and associated risks. I provide my consent to undergo red light therapy under these terms and conditions. I affirm that my participation in red light therapy sessions is entirely voluntary, and I reserve the right to discontinue the treatment at any time. I am under no obligation to continue or complete any specific number of sessions.
Patient Informed Consent for Iron Infusions
I understand that I am voluntarily choosing to receive an Iron Infusion at Revive Room LLC (DBA Intra-V). I acknowledge that I have been informed of the potential risks, benefits, and alternatives to this treatment and have had the opportunity to ask questions before proceeding.
1. Nature of the Procedure
Iron Infusion Therapy involves the intravenous (IV) administration of iron to help replenish iron stores in individuals with iron deficiency or anemia. The iron solution will be delivered directly into my bloodstream over a set period of time.
2. Potential Benefits of Iron Infusions
I understand that Iron Infusions may provide the following benefits:
- Rapid replenishment of iron levels.
- Increased energy, improved focus, and reduced fatigue in those with iron deficiency.
- Avoidance of gastrointestinal side effects associated with oral iron supplements.
- Improved oxygen transport and circulation in the body.
I acknowledge that the results of iron infusion therapy vary from person to person and that no guarantees have been made regarding the effectiveness of the treatment for my specific condition.
3. Potential Risks & Side Effects
I understand that receiving an Iron Infusion may involve certain risks, including but not limited to:
Mild to Moderate Side Effects:
- Temporary flushing, dizziness, headache, or metallic taste during the infusion.
- Nausea, vomiting, or abdominal discomfort.
- Low blood pressure or fainting due to rapid administration.
- Pain, swelling, or irritation at the injection site (phlebitis).
Severe Risks & Reactions (Rare but Possible):
- Anaphylaxis (a severe allergic reaction that may require emergency treatment).
- Breathing difficulties, chest tightness, or throat swelling.
- Severe hypotension (low blood pressure).
- Iron Overload (excess iron accumulation, which can cause long-term complications).
- Hemosiderosis or liver toxicity (in individuals with undiagnosed conditions).
- Severe pain, staining, or burning at the infusion site due to iron leakage into surrounding tissues.
I understand that certain individuals are at higher risk for adverse reactions, including those with a history of allergies to iron infusions, multiple drug sensitivities, or specific medical conditions.
4. Contraindications & Medical History Disclosure
I affirm that I have disclosed my complete medical history and that I:
- DO NOT have a history of severe allergic reactions to IV iron products.
- DO NOT have hemochromatosis (iron overload disorder) or any other condition that may cause excessive iron accumulation.
- DO NOT have active liver disease or severe kidney disease.
- DO NOT have an ongoing infection or inflammatory disorder that may be worsened by iron infusion therapy.
I acknowledge that failure to disclose accurate and complete medical information may increase my risk of adverse effects.
5. Monitoring & Emergency Protocol
I understand that my iron infusion will be administered by trained medical professionals who will monitor me for adverse reactions. In the event of a severe reaction:
- The infusion will be stopped immediately.
- Emergency medications, including antihistamines, steroids, or epinephrine, may be administered if necessary.
- I may be referred for further medical evaluation if complications arise.
6. Alternative Treatment Options
I understand that alternatives to iron infusions include:
- Oral iron supplements (which may cause gastrointestinal side effects).
- Dietary modifications to increase iron intake naturally.
- Blood transfusions in cases of severe anemia.
I acknowledge that I have been given the opportunity to discuss these alternatives with my provider.
7. Financial Responsibility & No Refund Policy
I understand that Iron Infusions are elective treatments and that:
- I am financially responsible for all services received.
- No refunds will be issued for completed treatments, regardless of the outcome.
- I understand that if I experience any side effects or require additional medical attention outside of Intra-V’s services, I am responsible for any additional costs.
8. Voluntary Consent & Acknowledgment
By signing below, I acknowledge that:
- I have read and understand this Iron Infusion Consent & Waiver.
- I have had the opportunity to ask all questions regarding the procedure, risks, and alternatives, and I am satisfied with the information provided.
- I voluntarily consent to receiving Iron Infusion Therapy and assume all associated risks.
- I understand that I may withdraw my consent at any time before or during the procedure.
- I release Revive Room LLC (DBA Intra-V), its providers, nurses, employees, and affiliates from any liability related to the treatment, except in cases of gross negligence or misconduct.
Peptide Therapy Medical Waiver and Informed Consent
1. Purpose of Treatment
I understand that I am voluntarily choosing to undergo peptide therapy through Intra-V for purposes that may include, but are not limited to, anti-aging, hormone optimization, recovery, immune support, tissue repair, weight loss, and sexual health.
Peptide therapy includes the use of biologically active amino acid sequences prescribed to support or stimulate specific functions in the body.
2. Nature of Treatment
I understand that peptides offered by Intra-V may include (but are not limited to): BPC-157, CJC-1295 / Ipamorelin, Sermorelin, Tesamorelin, GHK-Cu, PT-141, MOTs-C, AOD 9064, TB500, Epithalon, Kisspeptin. I understand that these treatments may be prescribed in subcutaneous injectable, topical and oral form, and are to be administered as directed by Intra-V’s medical staff.
3. Off-Label Use and FDA Status
I acknowledge that many peptides are not FDA-approved for all uses listed above and may be considered “off-label” use of a compounded medication. I understand that while there is scientific evidence supporting the effectiveness of certain peptides, not all therapies are widely studied in large-scale human trials.
4. Risks and Side Effects
I acknowledge that, as with any medical therapy, there are potential risks, which may include but are not limited to:
- Injection site discomfort, redness, or irritation
- Allergic reaction or hypersensitivity
- Headache, dizziness, fatigue
- Water retention or bloating
- Hormonal changes or imbalances
- Nausea or upset stomach
- Death
I understand that adverse effects are rare but possible, and I agree to report any unusual symptoms or concerns to the medical staff immediately.
5. No Guarantees
I acknowledge that Intra-V has made no guarantees regarding the outcome or success of peptide therapy. I understand that individual responses to peptide therapy vary, and results are not guaranteed.
6. Voluntary Participation and Medical Oversight
I confirm that:
- I am undergoing this treatment voluntarily.
- I have disclosed my full medical history to Intra-V staff.
- I understand that peptide therapy should be administered under medical supervision.
- I will follow all treatment protocols, dosing instructions, and follow-up recommendations provided.
7. Pregnancy and Fertility
I affirm that I am not currently pregnant, breastfeeding, or trying to conceive. I understand that certain peptides may affect hormone levels, fertility, or fetal development and should not be used during pregnancy or while nursing.
8. Release of Liability
In consideration of receiving peptide therapy from Intra-V, I hereby release Intra-V, its medical director, providers, staff, owners, and affiliates from any and all liability, claims, or causes of action arising from or related to my participation in this therapy.
I assume full responsibility for any risks, known or unknown, associated with this treatment.
9. Acknowledgment and Consent
I confirm that I have read and fully understand this medical waiver and informed consent form. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
I understand that I may discontinue treatment at any time and that it is my responsibility to inform the staff if I wish to do so.
All sales are final.
The signer understands that all sales for current or future services purchased from Intra|V are final and will not be issued a refund. The signer knows of the risks and potential side effects and understands that these said risks do not warrant a refund for current or future services purchased. These Risks and potential side effects may include but are not limited to discomfort, bruising, and pain at the site of injection, inflammation of the vein used for injection, phlebitis, metabolic disturbances, injury, severe reaction, anaphylaxis, cardiac arrest, or death.
My signature below confirms that:
1. I have received all the information and explanation I desire concerning the procedure.
2. I authorize and consent to the performance of the procedure(s)
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PARENTAL CONSENT
Date:
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