Intravenous (IV) Infusion Therapy Informed Consent Form
This consent form is intended to document that you have been informed about the risks and benefits of Intravenous (IV) Infusion Therapy (“IV Therapy”) as ordered by the medical provider(s) at Ikigai Energy, in addition to the availability of alternatives., This form serves as an informed consent you have had reviewed the provided medical information and have been provided an opportunity to ask questions about IV Therapy, and that you voluntarily consent to the treatment.
What is IV Therapy
IV Therapy is a means to deliver vitamins, minerals and other nutrients to the body while bypassing the digestive system. The IV Therapy procedure involves inserting a needle into the vein leaving a soft catheter in place while an infusion of Normal Saline 0.9% or Lactated Ringers solution mixed with selected IV Therapy nutrients (vitamins, minerals, amino acids, glutathione, electrolytes, sugars, and diluents) infuses over a
duration of time. The Ikigai Energy medical provider(s) will recommend a solution of nutrients that fits your
needs, based on the complete medical information provided by the patient. Should you feel uncomfortable with
your IV Therapy at any point, please call for the Ikigai Energy medical provider for assistance.
Who should not receive IV Therapy?
Any person who has known or suspected advanced heart, liver, or kidney issues or dysfunctions or who have a G6PD deficiency should not receive IV Therapy. Also, women who are or suspect that they may be pregnant or women who are breastfeeding should not receive IV Therapy. Do not receive IV Therapy if you have been directed by a medical professional to avoid such procedures.
Is IV Therapy covered by insurance?
IV Therapy is not covered by insurance. All infusions require upfront payment prior to receiving therapy.
The Benefits of IV Therapy include but are not limited to the following:
Nutrients infused into the bloodstream are better absorbed by the body, as they are not affected by stomach or intestinal absorption disturbances.
Higher doses of nutrients can be given intravenously rather than orally without intestinal irritation and with greater availability to your body's cells and tissues.
IV Therapy is not covered by insurance. All infusions require upfront payment prior to receiving therapy.
The Risks of IV Therapy inclusive of but not limited to:
Some patients may experience discomfort, redness, swelling, bruising and/or bleeding at the injection site.
It is possible that the vein used for infusion may become inflamed, infected, and/or damaged. There could also be injury or inflammation of the nerves and/or muscle at the injection site.
On rare occasions, patients have experienced temporary metabolic disturbances such as temporary changes in blood sugar and/or blood pressure leading to lightheadedness, dizziness, or passing out, and/or increased thirst.
Allergic reactions, anaphylaxis, infection, injury, cardiac arrest, and death caused or precipitated by IV Therapy are extremely rare but not unheard of.
Alternatives to IV Therapy Include:
Consuming water and supplements by mouth.
Transdermal application of certain substances, such as through a Vitamin B12 patch.
Dietary and/or lifestyle changes.
No treatment period.
Is IV Therapy a Guarantee to Cure/Fix My Conditions?
Ikigai Energy makes no guarantees that IV Therapy will provide adequate therapeutic benefits or that it will
cure any medical conditions. IV Therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical condition. IV Therapy is not a substitute for your primary provider's medical care.
My Signature Above Confirms My Understanding Of The Following:
I have read and fully understand all the information set forth above.
IV Therapy procedure, benefits, risks and alternatives have further been adequately explained to me by the Ikigai Energy provider(s). I understand that I must call for the medical provider if I experience any discomfort during my IV Therapy session.
I have been given the opportunity to ask questions to the Ikigai Energy medical provider (s) to better understand the IV Therapy procedure, benefits, risks and alternatives and have had such questions adequately answered.
I have provided accurate and complete medical information to the best of my knowledge to Ikigai Energy on the assessment form, including the disclosure of all medications, supplements, vitamins, and substances that may be in my system, as well as all known allergies and medical conditions. I understand that Ikigai Energy will use this information to make recommendations that are best for me relating to IV Therapy.
I am aware that unforeseeable complications could occur. I do not expect the nurse(s) and/or provider(s) to anticipate and or explain all risks and possible complications. I rely on Ikigai Energy provider(s) to exercise judgment during treatment with regards to my procedure.
I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its initiation. My signature and initials on this form affirms that I have given my consent to IV Therapy, including any other procedures which, in the opinion of my providers(s) or other associated with this practice, may be indicated.
I release Ikigai Energy, and each of its medical provider (s) and/or delegated staff from all liability whatsoever associated with the administration and receipt of IV Therapy that I have consented to, including to and without limitation liabilities resulting from complications.
IV Therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. Results are not guaranteed by Ikigai Energy. All IV Therapy vitamins, nutrients and medications have been fashioned in an FDA approved third party compounding pharmacy.
I have received all the information needed to make an informed decision regarding receiving IV Therapy. I give my informed consent to receive IV Therapy, and I authorize Ikigai Energy to administer said IV Therapy discussed with one of Ikigai Energy’s medical provider(s) to me.
This form is intended to document that you have been informed about the benefits and risks of Intravenous
(IV) Infusion Therapy (“IV Therapy”) as ordered by the medical provider(s) at Ikigai Energy, as well as the
availability of alternatives, that you have had a chance to review provided medical information and to ask
questions about IV Therapy, and that you voluntarily consent to the treatment.
