Allure Infusion IV Consent Form

Allure Infusion IV Consent Form

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ACKNOWLEDGEMENT

I am at or above the age of eighteen and consent to the insertion of a peripheral intravenous catheter (IV). I consent to the infusion of fluids, vitamins, minerals, and / or medications (if applicable). I agree and acknowledge no promises or guarantees were made regarding the efficacy of the infusion(s).

I further acknowledge that the infusion of vitamins, compounds, and/ or minerals have not been evaluated by the Food and Drug Administration (FDA) and that the infusion of such has no diagnostic value nor is the infusion a substitute, cure, therapy, or treatment for any disease or condition.

I agree and acknowledge no medical evaluation was performed prior to the use of the peripheral intravenous catheter by a physician or advanced practice provider (nurse practitioner or physician assistant), rendering me obligated to partake in these elective services.

I understand the infusion is being administered under the direction of Jeremy C. Storm, DO, and by a non-physician who is trained in the safe preparation, insertion, monitoring, stabilization, and removal of intravenous catheters and infusions, and has a non-impacted registered nurse license in the state of South Dakota.

I understand the benefits of IV infusions may be limited if I am an active smoker, live a sedentary lifestyle, and/or have a diet that contains an excess of calories and/or a deficiency of nutrients.

I understand that a series of infusions may be anticipated. I understand that infusion(s) may need to be repeated in the future in order to maintain the benefits.



RISKS

I acknowledge that I am aware of the risks inherent in peripheral vascular catheterization and infusion that include, but are not limited to: local irritation, pain, infection, phlebitis (irritation of the vein), venous thrombosis, shortness of breath, allergic reaction, fluid volume overload, medication interactions, and death. Despite these risks (and others) I consent to the injection of vitamins, compounds, and/ or minerals. I may withdraw my consent at any time.

I understand it is in my best interest to provide the registered nurse with a summary of any vitamins / supplements / compounds / minerals I currently take routinely, and I do not hold the registered nurse or Allure Health responsible for possible contraindications.

I answered / will answer the Medical Questionnaire truthfully and to the best of my knowledge. I release Allure Health and its staff of all responsibility should I falsify the information provided or refrain from disclosing certain diagnoses.



PAYMENT

Payment is due at the time of service. There has been no representation that this procedure is covered under my health insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless of infusion cancellation or if the infusion is stopped at any time prior to completion at the discretion of the registered nurse. I understand that I am responsible for the full cost of the infusion(s) and agree to pay.

The procedure(s) and this consent form have been adequately explained to me.

I certify that I am not pregnant. If I am uncertain of a pregnancy, I can request a urine pregnancy test at this office and will be responsible for the full costs associated with such a test. I certify that I am not intoxicated on alcohol or any illicit drugs.

I authorize and consent to the performance of the infusion(s). This consent is valid unless rescinded, which I can do at any time.



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