Terms and Conditions
Informed Consent For Intravenous (IV) Therapy
I am employing IV ASAP for intravenous administration, vitamin therapy, vitals, basic health risk assessments (prior to any service), and/or other related health services (not including medicine or any medical treatment), (collectively referred to as “IV Therapy”).
I understand that this Document is intended to serve as confirmation of informed consent for IV Therapy as ordered by a licensed physician and facilitated by IV ASAP.
I acknowledge that I am completing this Informed Consent truthfully, honestly, accurately, and to the best of my knowledge.
That I do not have a history of heart disease, diabetes, high blood pressure, swelling in the ankles, stroke, carotid vascular disease, and/or abdominal aortic aneurysm.
Prior to the service, I have/will inform the technician of any and all known allergies to the drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics.
Prior to the service, I have/will inform the technician of all current medications and supplements I am currently taking.
I acknowledge that the technician is using all new clean and sterilized materials, including needles, etc., and that I will watch the technician remove said items from their new, clean and sterile packaging.
I acknowledge that I am not now impaired and/or under the influence of illegal drugs and/or alcohol.
I acknowledge that during the procedure I will not be impaired by and/or be under the influence of any alcohol and/or illegal drugs and will confirm same with the technician upon their arrival.
I acknowledge that if the technician believes that I am impaired by and/or am under the influence of alcohol and/or illegal drugs, that in technician’s sole discretion, the technician may deny me the services, subject to the cancellation policy below.
I acknowledge that I will be physically present at the location where the IV Therapy to take place PRIOR to the technician’s arrival. I further acknowledge that if I am not physically present at the location where the IV Therapy is to be provided upon the technician’s arrival, that such services will be canceled subject to the cancellation policy below.
That I have read and agree to the Cancellation Policy Below.
Medical information, personal information, and history divulged during my IV Therapy will be kept strictly confidential unless I consent to sharing my information by way of a signed release.
I understand that I have the right to be informed during the procedure, and the risks and benefits. except in emergencies.
Procedures are not performed until I have had the opportunity to receive such information and have given my informed consent by executing this document.
The IV Therapy intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamin, minerals, and amino acids).
I understand that risks, benefits and alternatives to IV’s may include but are not limited to:
- 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.
- The Benefits
- Injectables are not affected by stomach or intestinal disease.
- Total amount of infusions enters the bloodstream and is available to the tissues.
- Higher doses of nutrients can be given by vein that by mouth without intestinal irritation that can accompany doses given by mouth.
- Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes.
I understand that IV Therapy is not a substitute for medicine, medical treatment, or the diagnosis, treatment, or cause of disease by a medical provider.
I am aware that other unforeseeable complications could occur. I do not expect the technician(s) to exercise judgement during the course of treatment with regards to my IV Therapy. I understand the risks and benefits of the IV Therapy and will have the opportunity to have all 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, subject to the cancellation policy below. With that said, by clicking “I Accept” I affirm that I have given my consent for IV therapy with any different or further procedures, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
Cancellation Policy: If your appointment is not cancelled two hours prior to your scheduled services, you will be charged in accordance with the below:
- If you cancel within the TWO HOURS prior to your scheduled services you will be charged full price for your requested service.
- If you cancel, refuse to consent, and/or refuse the services once the technician has arrived or anytime thereafter, you will be charged full price for your requested service.
- If the technician arrives for your scheduled service and you are not physically present at the location where the services are to take place, you will be charged full price for your requested service.
- If the technician, in their sole discretion, believes that you are impaired by and/or are under the influence of alcohol and/or illegal drugs, and the technician denies you services, you will be charged full price for your requested service.
I agree to hold IV ASAP harmless for claims or damages in connection with IV Therapy, I understand that this is a release of potential liability.
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 have been adequately explained to me by the technician. I understand that I am free to withdraw my consent and to discontinue participation in their treatment at any time.
By Clicking “I Accept” I confirm that:
- I have received all the information and explanation I desire concerning the procedure.
- I authorize and consent to the performance of the procedure(s)