I understand this procedure is recommended for the replacement of fluids and/or nutrients, correction of deficiencies and other therapeutic effects. I understand this procedure is considered medically unnecessary and “experimental” by some medical providers. It is not intended to mitigate alleviate, cure, or treat my medical conditions. I have been advised that other treatments can been used to treat my current conditions, including, but not limited to, prescription medication, over-the-counter medication, and nutritional supplements, and these have been explained to my full satisfaction.
I understand that the benefit of IV nutrient therapy is much greater if I follow a healthy lifestyle (Non-smoking, weight control, proper exercise and diet). I understand, as with any other medical procedures, a small percentage of patients do not respond to this therapy and possibly have adverse reactions. I have informed the Provider performing the IV nutrient therapy of any allergies to drugs or substances that may be included in my IV solution and of any prior reactions to IVs. I have informed the Provider of all of my medications and supplements that I have or am currently taking.
The IV procedure involves inserting a needle and catheter into my vein and infusing fluids that have nutrients, vitamins, and minerals, as discussed with me prior to treatment and I have agreed upon.
I understand the benefits of IV therapy allow for higher concentrations of vitamins, minerals, and amino acids in my blood stream. This also works to bypass the liver’s metabolism of substances and the degradation of substances from the GI tract.
I understand that there is no implied or stated guarantee of success or effectiveness of the IV nutrient therapy I am about to receive. The procedure has been adequately explained to me by my Provider, and I understand I am free to withdraw my consent and discontinue treatment at any time.
I understand that IV nutrient therapy may cause: burning/stinging/swelling at the site of infusion, weakness, fatigue, allergic reaction, muscle spasms, local thrombophlebitis, air embolism, congestive heart failure, lowering of blood sugar, fever, chills, cardiac arrest, stroke, or even death.
Restorative MediSpa, PLLC (RMS) always respects the privacy of our patients. Ensuring that medical information is kept confidential is among one of our highest priorities. RMS seeks your permission to use pictures, audio and or video of you before, during or after receiving treatment from RMS. This material can be used in, but not limited to: internal and external communications, medical and general interest publications, medical and patient education information and distrusted such material online, in print, in news media and social media (Facebook, Instagram, Twitter, etc).
To ensure RMS is acting in accordance with your wishes, and using your personal information with your authorization, we ask you to fill out and sign the following form. RMS will keep a copy of this form and your written permission on file.
I understand I am not required to sign this authorization. RMS does not condition treatment, payment, benefits or enrollment into the clinic on the signing of this form. I can request a copy of this authorization to be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of any information and audio/video/photographic material.
If I decide to sign this form, I have the right to request that audio/video recording, filming or photographing cease at any time.
I am aware that my protected health information will exist forever in either a recorded, printed, and/or electronic version or other versions as may develop over time and that once it is published or disclosed in any form it will continue to be used. I understand that information about me used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and other applicable federal and state law.
I understand that I may revoke or with drawl this permission at any time to prohibit future use of my information. To do so I must send a written notice to RMS at 2150 E. Highland Ave #107, Phoenix, AZ 85016. I understand that RMS, as well as other persons or entities, will retain copies of any such electronic or printed versions and shall retain these versions previously published. If not revoked/withdrawn by me, this authorization expires in ten (10) years from the date that I sign it.
I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may cause side effects when they interact with Vitamin B12, Vitamin B Complex, and MIC injections. I have notified the Provider of any medications, both prescription and non-prescription, supplements, and vitamins that I may be taking. I understand vitamins and nutritional supplements are not intended to diagnosis, treat, cure, or prevent any disease or illness.
By signing below, I acknowledge that I have read the above information discussing IV nutrient therapy and that the procedure and possible side effects have been thoroughly explained to me. I understand this procedure is elective, and I accept the associated risks. I hereby give consent for Restorative Care Arizona to perform this IV nutrient therapy and all subsequent IV Nutrient therapy injections as discussed above. I hereby release Restorative MediSpa, PLLC, and the Provider from any and all liability associated with this procedure.