This document is intended to serve as informed consent for your Intravenous (IV) Infusion Therapy as ordered by the physician at Five Journeys.
(Initials)* I have informed the nurse and/or physician of any known allergies
to medications or other substances and of all current medications and supplements.
I have fully informed the nurse and/or physician of my medical history.
(Initials)* 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.
(Initials)* 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.
(Initials)* I understand that:
1. The procedure involves inserting a needle into a vein and injecting the prescribed
2. Alternatives to intravenous therapy are oral supplementation and / or dietary and
3. Risks of intravenous therapy include but not limited to:
(Initials)* 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 understand the risks
and benefits of the procedure and have had the opportunity to have all of my
(Initials)* I understand that I have the right to consent to or refuse any
proposed treatment at any time prior to its performance. My signature on this form
affirms that I have given my consent to IV Infusion Therapy, including any other
procedures which, in the opinion of my physician(s) or other associated with this
practice, may be indicated.
My signature below confirms that:
1. I understand the information provided on this form and agree to all statements
2. Intravenous (IV) Infusion Therapy has been adequately explained to me by my
nurse and/or physician.
3. I have received all the information and explanation I desire concerning the
4. I authorize and consent to the performance of Intravenous (IV) Infusion Therapy.
5. I release Dr. Levitan at Five Journeys, and all the medical staff from all liabilities for
any complications or damages associated with my Intravenous (IV) Infusion Therapy.
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Testing: $138DMSA: $36