INTRAVENOUS (IV) INFUSION THERAPY INFORMED CONSENT

TO OUR PATIENTS: You have the right to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after learning the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

Indications
IV vitamin hydration therapy is designed to counteract symptoms of dehydration, fatigue, and the residual effects of alcohol ingestion, vitamin, mineral, and other nutritional deficiencies, metal toxicity, and exposure to environmental toxins. The procedure involves inserting a needle into your vein, placing a catheter, then withdrawing the needle and receiving an infusion of fluids combined with vitamins, minerals, and/or amino acids directly into the bloodstream. You may also receive an intramuscular injection of specific nutrients.

Results
I understand that an initial series of treatments are anticipated that may extend over a number of weeks or months. I understand that it is my option to discontinue this treatment protocol at any time. As with any medical procedure, a small percentage of clients do not respond to this therapy. Most patients receiving IV Infusion Therapy claim to feel an improvement in symptoms; however, every individual is different and results are not guaranteed. I have been advised that there are other treatment approaches for my symptoms/conditions, including but not limited to prescription medications, over-the-counter drugs, and nutritional supplements and these alternatives have been explained to my full satisfaction.

Side effects, complications, and risks include but are not limited to:
Discomfort, bruising, pain at the injection site; Inflammation of the vein used for injection (phlebitis); Metabolic disturbances; Severe allergic reaction, anaphylaxis, cardiac arrest, and in rare cases, death.

Benefits of IV therapy:
IV ingredients are not affected by stomach or intestinal disease; 100% absorption of nutrients with the total amount being available to tissue; Nutrients are forced into cells by means of a high concentration gradient; Higher doses of nutrients can be given than possible with oral doses, without intestinal irritation.

I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, proper exercise, proper diet, and nutritional supplements).

I have been informed of the nature of the proposed therapy and possible risks and side effects including but not limited to discomfort, bruising or pain at the injection site, thrombophlebitis, fatigue, allergic reaction, congestive heart failure, lowered blood sugar levels, fever, or chills.
I understand that I should not use IV therapy if I am pregnant unless recommended by a physician.

I understand that IV therapy is not intended to cure, prevent, or treat any disease. All medical problems should be cleared by my primary care physician.

I understand these therapies are not FDA approved.

I acknowledge I have read the above information and agree to treatment and associated risks. My signature on this agreement constitutes a full release of any legal responsibility on the behalf of Med 1 Aesthetics or any of their clinicians or staff, resulting from the administration of intravenous nutrient therapy in my case and/or any other medical treatments that may be necessary as a result thereof. I hereby give consent to Med 1 Aesthetics to perform intravenous vitamin and mineral therapy and all subsequent treatments with the above understood.

LIPOTROPIC INJECTION THERAPY INFORMED CONSENT

TO OUR PATIENTS:

You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.

Lipotropic Injections have been shown to be beneficial in reducing stress and fatigue, improving memory and cardiovascular health, and maintaining healthy body weight. It can aid the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes.

Potential risks and side effects:
· Common risks and side effects include mild diarrhea, upset stomach, nausea, pain, bruising, redness, bleeding, and/or a warm sensation at the injection site, allergic reaction or itching peripheral vascular thrombosis, a feeling, or a sense, of being swollen over the entire body, headache, and joint pain. These are usually minimal and dissipate in a minimal amount of time.
· Other uncommon but serious side effects: rapid heartbeat, chest pain, flushed face, muscle cramps, weakness, difficulty breathing and swallowing, dizziness, confusion, tightness in the chest, hives, skin rashes, shortness of breath even with no physical exertion, and unusual wheezing and coughing.
· Certain herbal products, vitamins, minerals, nutritional supplements, and prescription and non-prescription medications may result in side effects when they interact with the vitamin injection.

Contraindications:
· Patients with an anxiety disorder and/or taking anxiety medications
· Patients with pre-existing cardiovascular or thyroid conditions
· Patients who are pregnant, may become pregnant, or are breastfeeding.
· Patients with: Leber’s disease, kidney disease, liver disease, infection, iron deficiency, folic acid deficiency, receiving treatment that affects bone marrow, taking any medication that affects bone marrow, an allergy to cobalt, other medications, vitamins, dyes, foods or preservatives.

I understand that each patient responds differently to medication and may respond differently from one treatment to the next. As with all medicines, results are temporary and regular dosing is necessary. The length of time the injectable medication lasts varies in each patient and no guarantees are made with regard to your results and the efficacy of the medication. I will inform my practitioner of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any further treatments.

I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment and that all prices are subject to change without prior notice.

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

INFORMED CONSENT | Intramuscular Injection

TO OUR PATIENTS: You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold,

your consent for treatment.

1. I understand that I will be treated with lipotropic vitamin injection into the following area(s):

2. I understand that no warranty or guarantee has been made to me regarding my results from this treatment. I understand that more than one injection may be required to achieve noticeable and/or satisfactory results.

3. I understand and agree that all services rendered to me are charged directly and that I am personally responsible for payment. Note: All prices are subject to change without prior notice.

The following risks may occur with injections: bleeding, bruising, redness, pain, scarring, swelling, discoloration, infection, raised bumps of skin (nodules), headache, allergic reactions, upset stomach, death These risks are not meant to be all-inclusive as there are both known and unknown side effects associated with any medication. I will follow all care and aftercare instructions.

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative treatment methods and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

By signing below, I acknowledge I have read the above information and agree to treatment and associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood.

Please sign and agree to these terms below.