IV Therapy Intake Form

This Document is intended to serve as confirmation of informed consent for IV therapy performed at Pathway Wellness or Midtown Movement and Medicine. I have informed the clinic and Dr. Jeffrey Farrah, DC, ARNP of any known allergies to drugs or others substances, or of any past reaction to anesthetics. I have informed the doctor of all current medications and supplements. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. I understand that: a. The procedure involves inserting a needle into a vein and injecting the prescribed solution. b. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes. c. Risks of intravenous therapy include: i. Occasionally to commonly: Discomfort, bruising and pain at the injection site. ​ii. Rarely: Inflammation of the vein used for injection called phlebitis. iii. Extremely Rarely: Severe allergic reaction, anaphylaxis, cardiac arrest and death d. Benefits of intravenous therapy include: i. Injectables are not affected by the stomach, or intestinal absorption problems. ii. The total amount of the infusion is available to the tissues. iii. Nutrients are forced into cells by means of a higher concentration gradient. iv. Higher doses of nutrients can be given than is possible by mouth without intestinal irritation. I am aware that other unforeseeable complications could occur. My physician has explained these risks to me as well as other options for treatment including receiving no treatment and the probable outcomes. I understand the risks and benefits of the procedure and I have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or to refuse any proposed treatment at any time prior to it's performance. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedures which, in the opinion of my physician, may be indicated. My signature below confirms that:a. I understand the information provided on this form and agree to the foregoing. b. The procedures set forth above have been adequately explained to me by my physician. c. I have received all the information and explanation I desire concerning the procedures. d. I authorize and consent to the performance of the procedure(s).