Informed Consent for IV Therapy

This document is intended to serve as informed consent for Intravenous (IV) Infusion Therapy

I, the undersigned client, consent to treatment from Paging Dr. Neil (“Practice”). I acknowledge and agree that I understand the risks associated with intravenous (IV) Infusion Therapy and the services provided by duly licensed medical professionals. I acknowledge that the services and any medication prescribed, as applicable, has been prescribed based on my honest and truthful description of past medical history and current symptoms. I understand that neglecting to share complete and accurate records may result in personal injury. 

I acknowledge and understand that the Practice is relying upon the foregoing representations and warranties from me upon Practice’s acceptance of me for participation in its programs and services. I acknowledge and understand that the Practice is not responsible or liable for any complications that result from the use of any client provided or custom requested vitamins, injections, or medication.

I understand that this consent is valid for the date of a single visit and must be completed upon each treatment session moving forward. I understand I may withdraw my consent at any time by written notice to the Practice, and if done so, the services will either be stopped immediately or not be provided thereafter, at practice’s sole discretion. I understand that admission to and continuation of practice’s services are subject to the practice’s policies and procedures which includes, but is not limited to, revoking service at any given time should there be an identified unsafe environment for our clinicians. 

I understand that the Practice makes no warranties or guarantees regarding the treatment outcome and despite this, I desire to undergo treatment. I represent that I have received a thorough explanation as to the risks associated with the treatments.

I understand that Intravenous infusion 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. These IV infusions are not a substitute for your physician's medical care.

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.

1. The procedure involves inserting a needle, followed by angiocatheter, into a vein and injecting the prescribed solution. 

2. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes. 

3. Risks of intravenous therapy include but not limited to: a) Occasionally: Discomfort; bleeding; bruising and scarring resulting from IV infiltration, extraction, extravasation, and injection; misplacement of IV lines in the body; medication adverse reactions. b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, nerve injury, lightheadedness, fainting, c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, air embolism, cardiac arrest and death. 

4. Benefits of intravenous therapy include: a)Injectables are not affected by stomach, or intestinal absorption problems. b) c) Nutrients are forced into cells by means of a high concentration gradient. d) Higher doses of nutrients can be given than possible by mouth without intestinal irritation. 

I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or physician(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or physician(s) to exercise judgment during the course of treatment with regards to my procedure. 

I expressly represent and warrant that I am not a user of illegal drugs and/or controlled substances and am not under the influence of the same, or recovering from use of the same at the time of the provision of services.

I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events associated with the services and will not hold the providers, Paging Dr. Neil / Dr. Neil Panchal (the “Releasees”) liable for any unfavorable outcome or adverse event. I release the Releasees, owners, and medical staff from liability associated with any of the services. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns (the “Releasors”). This release shall be governed by the laws of New Jersey. In the event any provision of this release is found to be overly broad in time, scope or otherwise or illegal, invalid, or void for any reason such provision shall be revised to the minimum extent required to make such provision enforceable and valid and the revised provision shall be made a part of this release as if it were set forth in the body of this release.

I confirm and agree with the recommended services and am aware that all matters can be discussed further with the supervising practitioner and/or clinician [registered nurse] at the time of my visit. I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND ANY QUESTIONS I HAVE ASKED HAVE BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY MANNER.

By signing, I understand and agree with this consent willingly and voluntarily.