Intravenous (IV) Infusion Therapy Informed Consent Form

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 at SureAccessMD ("SureAccess"), 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.

What is IV Therapy? IV Therapy is a means to deliver vitamins, minerals and other nutrients to the body while avoiding the digestive process. The IV Therapy procedure involves inserting a needle into the vein and infusing or injecting a solution of nutrients (vitamins, minerals, amino acids, glutathione, electrolytes, sugars, and diluents) over a period of time. The SureAccess medical provider 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 SureAccess medical provider for assistance.

The benefits of IV Therapy include:

• Nutrients infused into the bloodstream are better absorbed by the body, as they not affected by stomach or intestinal absorption disturbances.
• Higher doses of nutrients can be given intravenously than by mouth without intestinal irritation and with greater availability to your body's cells and tissues.

The risks of IV Therapy include:

• 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 B12 patch.
• Dietary and/or lifestyle changes.
• No treatment whatsoever.

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 will require payment in advance of receiving therapy.

Is IV Therapy guaranteed to cure my issues?
We make no guarantees that IV Therapy will provide adequate therapeutic benefits or that it will cure any medical issues. 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. IV Therapy is not a substitute for your physician's medical care.

My signature below confirms that:

1. I have read and fully understand all of the information set forth above.


2. IV Therapy procedure, benefits, risks and alternatives have further been adequately explained to me by the SureAccess provider. I understand that I must call for the medical provider if I experience any discomfort during my IV Therapy.


3. I have been given the opportunity to ask questions to the SureAccess medical provider to better understand the IV Therapy procedure, benefits, risks and alternatives and have had such questions adequately answered.


4. I have provided accurate and complete medical information to SureAccess 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 issues. I understand that SureAccess will use this information to make recommendations that are best for me relating to IV Therapy.


5. I am aware that 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 SureAccess providers to exercise judgment during the course of treatment with regards to my procedure.


6. 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 Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.


7. I release SureAccess, and each and every physician and medical provider and staff from all liability whatsoever associated with the administration and receipt of IV Therapy, including without limitation liabilities resulting from complications.


8. 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 SureAccess.


9. I have received all of the information needed to make an informed decision regarding receiving IV Therapy. I give my informed consent to receive IV Therapy and I authorize SureAccess to administer said IV Therapy to me.