INFORMED CONSENT FOR IV-THERAPY

CONSENT FOR CARE

You approve, authorize Praesidium Diagnostics dba Sameday Health and AR Medical, and any employee working under the direction of the physician, to provide medical care, or to this patient for which you are the legal guardian. This medical care may include services and supplies related to your health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment. 

You understand during the course of the proposed treatment(s), test(s), or examination(s) unforeseen conditions may arise which may necessitate additional treatment(s), test(s), or examination(s). You consent to the performance of additional treatment(s), test(s), or examination(s).


CONSENT FOR IV-THERAPY

This document is intended to serve as confirmation of informed consent for IV therapy as ordered by Neudrip. You have informed the provider of any known allergies to drugs, supplements, or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics. In doing so, you understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with you insofar as to the extent to which you do not disclose those allergies in advance.

You have informed the provider of all current medications and supplements. In doing so, you understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with you in so far as to the extent to which you do not disclose my health conditions, medications, or supplements in advance.

You have informed the provider of all medical conditions, diseases, and illnesses. You attest that you have never been diagnosed with or treated for any such conditions that would put you at increased risk while receiving IV therapy services by Neudrip. You understand that you will be screened for said conditions prior to initiation of services.

You understand that you have the right to be informed of the risks and benefits before therapy administration. No procedures will be performed until you have had an opportunity to receive such information and to give you informed consent. Neudrip therapies are not intended for emergency care. The intravenous (IV) procedure involves inserting a needle into your vein and infusing the prescribed nutrients and/or medications over a determined period of time. That time will vary depending on your anatomy and infusion rate, however the therapy should be expected to take about 30 to 60 minutes.

You understand that IV therapy carries with it both risks and benefits. Some of those risks and benefits include, but are not limited to:

The Risks and potential side effects

  1. Discomfort, soreness, bleeding, bruising, pain and possible scarring at the site of injection.

  2. Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

  3. Lightheadedness or fainting.

  4. Severe reaction to medication, supplement or vitamin therapy; anaphylaxis, cardiac arrest or death.

  5. Volume overload.

  6. Air embolism.

  7. Infiltration

The Benefits

  1. Injectables are not affected by stomach or intestinal disease.

  2. Total amount of infusion enters the bloodstream and is available to the tissues.

  3. Higher doses of nutrients can be given by vein than by mouth,

  4. Can be used in conjunction with oral supplementation and/or dietary and lifestyle changes.

You are aware that other unforeseeable complications could occur. You understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. You understand that you have the right to consent to or refuse any proposed treatment at any time before or during its performance. You consenting to this form affirms that you have given my consent to IV therapy with any different or further procedure/medications, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.

Lastly, you attest that you are not under the influence of illegal drugs or substances at the time of therapy. You agree that you am not using said therapy to recover from any drug related symptoms. You understand that if any suspicion of such is made by the provider, my right to therapy administration will be waived and will not be subject to a refund.

You understand that a record of my treatment will be generated with each visit. We are committed to your privacy and all health care information provided to Sameday Health and affiliated companies will be protected. Any disclosures of PHI (protected health information) will therefore require authorization unless used in the following ways:

  1. Quality improvement regarding Sameday Health

  2. Health-related benefits and services referral

  3. Any court-ordered requests or subpoenas

  4. Any law or government mandates with an appropriate warrant

You understand the information provided on this form and agree to all therein. You 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 my provider. You understand that you are free to withdraw my consent and discontinue participation in their treatments at any time.

You understand that, except in emergencies, you must give 24 hours notice of intent to cancel or reschedule my appointment. You understand that you will incur the full fee for treatment, regardless of amount of supply used due to wasted materials.