IV Vitamin Hydration 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 and/or 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

Side effects, complications, and risks include, but are not limited to:

• Discomfort, bruising, or pain at the injection site
• Inflammation of the vein used for injection (phlebitis)
• Metabolic disturbances
• Severe allergic reaction
• Anaphylaxis
• Cardiac arrest
• In rare cases, death

Benefits of IV Therapy

Benefits of IV therapy include:

• IV ingredients are not affected by stomach or intestinal disease.
• 100% absorption of nutrients, with the total amount being available to body tissues.
• Nutrients are delivered directly into cells through a high concentration gradient.
• Higher doses of nutrients can be administered than are possible with oral supplements, without intestinal irritation.

I understand that the benefits of intravenous nutrient therapy are significantly greater when combined with a healthy lifestyle, including:

• Not smoking
• Maintaining a healthy weight
• Regular exercise
• Proper nutrition
• Appropriate nutritional supplementation

I have been informed of the nature of the proposed therapy and the possible risks and side effects, including but not limited to:

• Discomfort
• Bruising or pain at the injection site
• Thrombophlebitis
• Fatigue
• Allergic reactions
• Congestive heart failure
• Lowered blood sugar
• Fever
• Chills

I understand that I should not receive IV therapy if I am pregnant unless specifically recommended by a physician.

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

I understand these therapies are not FDA approved.

I acknowledge that I have read the above information and agree to treatment and its associated risks. My signature on this agreement constitutes a full release of legal responsibility on behalf of Med 1 Aesthetics and its clinicians and staff resulting from the administration of intravenous nutrient therapy and any other medical treatments that may become 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 understanding.

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Lipotropic Injection Therapy Informed Consent

To Our Patients

You have the right to be informed about your condition and its treatment so that you may decide whether or not to undergo the procedure after understanding the risks and hazards involved.

This disclosure is not meant to scare or alarm you; it is simply an effort to help you make an informed decision 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 supporting healthy body weight. They may also help the body convert proteins, fats, and carbohydrates into energy while supporting healthy skin and eyes.

Potential Risks and Side Effects

Common risks and side effects include:

• Mild diarrhea
• Upset stomach
• Nausea
• Pain
• Bruising
• Redness
• Bleeding
• Warm sensation at the injection site
• Allergic reaction
• Itching
• Peripheral vascular thrombosis
• Generalized swelling
• Headache
• Joint pain

These side effects are generally mild and typically resolve quickly.

Less common but more serious side effects include:

• Rapid heartbeat
• Chest pain
• Flushed face
• Muscle cramps
• Weakness
• Difficulty breathing or swallowing
• Dizziness
• Confusion
• Chest tightness
• Hives
• Skin rash
• Shortness of breath without physical exertion
• Unusual wheezing or coughing

Certain herbal products, vitamins, minerals, nutritional supplements, and prescription or over-the-counter medications may interact with vitamin injections and increase the risk of side effects.

Contraindications

Lipotropic injections may not be appropriate for:

• Patients with anxiety disorders or taking anxiety medications
• Patients with pre-existing cardiovascular conditions
• Patients with thyroid disorders
• Patients who are pregnant, planning to become pregnant, or breastfeeding
• Patients with:
  • Leber’s disease
  • Kidney disease
  • Liver disease
  • Active infection
  • Iron deficiency
  • Folic acid deficiency
  • Bone marrow disorders
  • Medications affecting bone marrow
  • Allergy to cobalt
  • Allergy to medications, vitamins, dyes, foods, or preservatives

I understand that every patient responds differently to medication and may respond differently from one treatment to the next.

As with all medications, results are temporary and ongoing treatments may be necessary. The duration of effectiveness varies among patients, and no guarantees have been made regarding results or treatment efficacy.

I agree to inform my practitioner of any changes in my medical history, medications, or other information relevant to this treatment before future appointments.

I understand and agree that all services rendered are my financial responsibility and that pricing is subject to change without notice.

The nature and purpose of this treatment have been explained to me.

I have read and understand this agreement.

All of my questions have been answered to my satisfaction.

Alternative treatment methods, along with their risks and benefits, have been explained to me, and I understand that I have the right to refuse treatment.

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Intramuscular Injection Informed Consent

To Our Patients

You have the right to be informed about your condition and its treatment so that you may decide whether or not to undergo the procedure after understanding the associated risks and hazards.

This disclosure is not meant to scare or alarm you. It is intended to help you make an informed decision regarding your treatment.

I understand that:

1. I will receive a lipotropic vitamin injection into the following area(s): __________________________
2. No warranty or guarantee has been made regarding my results. I understand that multiple injections may be necessary to achieve noticeable or satisfactory results.
3. All services rendered are charged directly to me, and I am personally responsible for payment. Prices are subject to change without prior notice.

Possible Risks

The following risks may occur with injections:

• Bleeding
• Bruising
• Redness
• Pain
• Scarring
• Swelling
• Discoloration
• Infection
• Raised skin bumps (nodules)
• Headache
• Allergic reactions
• Upset stomach
• Death

These risks are not intended to be all-inclusive, as both known and unknown side effects may occur with any medication.

I agree to follow all treatment instructions and aftercare recommendations.

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.

Alternative treatment options, along with 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 that I have read the above information, understand the associated risks, and voluntarily consent to this treatment and all subsequent treatments performed with the above understanding.