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Informed Consent for Intravenous (IV) Therapy or Intramuscular injections performed at Health Fusion Drip Spa

 

Informed Consent for Intravenous (IV) Therapy or Intramuscular injections performed at Health Fusion Drip Spa

Health Fusion Drip Spa is an innovative vitamin boost and IV/IM therapy clinic that takes an advanced approach to wellness. Founded and directed by experienced physician Dr. Cahn Nguyen, Health Fusion Drip Spa is dedicated to helping patients in achieve and maintain optimal health. The team of highly qualified staff at Health Fusion Drip Spa provide a comprehensive menu of services aimed at promoting, preserving, and protecting vitality, including intramuscular therapy, state-of-the-art IV therapy, and quick and easy vitamin boosts.  

Products and Services

We are providing IV and injection vitamin boosts. Vitamins and minerals are essential for the cells to function properly. Vitamin boosts and infusions are the fastest, most efficient way for your body to receive hydration and micronutrients. These essential nutrients are delivered in to the bloodstream where your cells can begin to uptake what your body needs right away.

This document is intended to serve as confirmation of informed consent for IV/IM therapy and boost

 I have informed the physician/registered nurse of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics.

I have informed the doctor/registered nurse of all current medications and supplements.

I understand that I have the right to be informed during the procedure, 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.

The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids).

The IM procedure involves inserting a needle into your muscle and injecting vitamins, minerals, amino acids or prescribed medications.

I understand that risks, benefits and alternatives to IVs may include but are not limited to:

  1. The Risks and potential side effects

    o Discomfort, bruising, and pain at the site of injection.
    o Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

    o Severe reaction, anaphylaxis, cardiac arrest, or death.

  2. The Benefits

    o Injectables are not affected by stomach or intestinal disease.
    o Total amount of infusion enters the bloodstream and ia available to the tissues
    o Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth.

  3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes.
  4. I am aware that other unforeseeable complications could occur. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.
  5. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
  6. I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures) set forth above has been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24 hours’ notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials

My signature below confirms that:

  1. I have received all the information and explanation I desire concerning the procedure.
  2. I authorize and consent to the performance of the procedure(s)

 

First Customer's Name

First Name*

Middle Name

Last Name*

Phone*
First Customer's Date of Birth*
First Customer's Signature*
Second Customer's Name

First Name*

Middle Name

Last Name*
Second Customer's Date of Birth*
Third Customer's Name

First Name*

Middle Name

Last Name*
Third Customer's Date of Birth*
Fourth Customer's Name

First Name*

Middle Name

Last Name*
Fourth Customer's Date of Birth*
Fifth Customer's Name

First Name*

Middle Name

Last Name*
Fifth Customer's Date of Birth*
Sixth Customer's Name

First Name*

Middle Name

Last Name*
Sixth Customer's Date of Birth*
Seventh Customer's Name

First Name*

Middle Name

Last Name*
Seventh Customer's Date of Birth*
Eighth Customer's Name

First Name*

Middle Name

Last Name*
Eighth Customer's Date of Birth*
Ninth Customer's Name

First Name*

Middle Name

Last Name*
Ninth Customer's Date of Birth*
Tenth Customer's Name

First Name*

Middle Name

Last Name*
Tenth Customer's Date of Birth*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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