I _________________________________________ hereby authorize the doctor(s) and nurses(s) at Core Cryotherapy to administer intravenous therapy to me. I understand that each physician independently contracts with the company, and is thus independently responsible for my medical care, and the company does not hold any responsibility for medical decisions made or treatments provided. I understand intravenous therapy is not a currently medically accepted procedure for treating any illness or concern and, thus, that it's used for this purpose may be considered by some insurance companies to be "medically unnecessary" or "experimental". I understand the procedure has some risks. Core Cryotherapy or his staff have explained to me verbally the short and long-term risk, which may include discomfort, bruising, infiltration, infection and pain at the injection site; temporary worsening of my current symptoms or headache, tachycardia (increased heart rate), syncope (fainting), visual difficulties, shortness of breath, joint pains, red eyes, itchy eyes, nasal congestion, numbness, gastrointestinal disturbances and a very rare but serious reaction called anaphylaxis. I also understand that other unforeseeable complications or side-effects could occur.
I understand the intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time the prescribe nutrients (vitamins, minerals, amino acids) or chelating agents. The intravenous treatment
has benefits that are as follows: IV's or injectables are not affected by stomach or intestinal disease; total amount of infusion enters the blood stream and is available to the tissues; higher doses of nutrients can be given directly into the muscle or vein than by mouth thereby bypassing intestinal irritation when given by mouth; the vitamins and might increase the over-all well being; and nutrients are forced into cells by means of a high concentration gradient. The possible benefits include mitigation or improvement of my current symptoms, improvement of respiratory function, decreased skin reactions, increased stamina, improved metabolism, to decrease in frequency or severity of headaches, improved concentration, and others.
I have read and understand the risks and benefits above and have had the opportunity to have all of my questions answered. I understand that I have the right to consent or refuse any proposed treatment at any time prior to the administering of my IV. 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 and that IV therapy may not mitigate, alleviate, or cure my condition(s). The procedure set forth above has been adequately explained to me. I understand that I am free to withdraw my consent and to discontinue participation and their treatments at any time. I understand that I must give 24-hour notice of intent to cancel or reschedule my appointment. I understand that 1 will incur the full fee for treatment, regardless of the amount used due to wasted materials.
My signature below confirms that I have received all the information and explanation that I desire concerning the intravenous
therapy procedure. My signature below also confirms that I have given my consent to the IV therapy at Core Cryotherapy.