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Hydrating A World Thirsty For Wellness

Consent for IM Injection


Patient Information:

    Informed Consent to Intramuscular Nutrient Injection Therapy

    The purpose of this Informed Consent to Intramuscular Nutrient Injection Therapy (IM Therapy) is to obtain your consent to the IM Therapy services offered by Deacon Medical Corp., the medical corporation providing the services under the DripLife IV brand. It is intended to document that you have been informed about the benefits and risks of IM Therapy as well as the availability of alternatives, that you have had a chance to ask questions about IM Therapy, and that you voluntarily consent to the treatment.

    All IM Therapy services are provided by Registered Nurses of Deacon Medical Corp. who are licensed to provide IM Therapy in California under the supervision of Dr. Deacon Farrell, MD.

    IM Therapy Procedure

    • The IM Therapy procedure involves inserting a needle into the muscle and injecting vitamins, minerals and glutathione. The procedure involves inserting a needle generally into the muscle of the thigh, shoulder, or upper buttocks..
    • IM Therapy is a means to deliver vitamins, minerals and other nutrients to the body while avoiding the digestive process. This is helpful in many cases where patients are depleted of certain nutrients and is especially helpful in conditions of decreased intestinal absorption of nutrients.

    Potential Benefits of IM Therapy depend on the substance(s) being injected. Such benefits include but are not limited to:

    • Injection into the muscles and tissue is not affected by stomach or intestinal absorption disturbances and therefore is better absorbed by the body. This can be especially helpful for individuals with conditions such as decreased intestinal absorption of nutrients, achlorhydria, long-term PPI use, and pernicious anemia.
    • Higher doses of vitamins, minerals and other substances can be given than is possible by oral consumption and without intestinal irritation that can accompany doses given by mouth.

    Potential Side Effects and Risks of IM Therapy include but are not limited to:

    • Discomfort such as redness, bruising, swelling, burning, stinging, pain, and/or bleeding at the site of the injection. The redness and swelling may last up to a few days.
    • Infection at the site of the injection.
    • Injury to nerve and/or muscle at the site of the injection.
    • Sensitivities or allergic reactions to the injection solution such as, for example, reactions to cobalt and/or cobalamin in injections containing B12 or reactions to anesthetics in injections containing lidocaine/procaine.
    • Mild diarrhea, upset stomach, nausea, increased urination, itching, headache, joint pain, racing heart, dizziness or a feeling of light-headedness after injections depending on the substance(s) in the injection.
    • It has been reported that B12 can cause itching, and a feeling of swelling in the body.
    • In rare cases, severe allergic reaction and anaphylaxis to the injection solution.

    Contraindications depending on IM Therapy solution, may include but are not limited to:

    • Known liver and/or kidney dysfunction
    • Sensitivity to cobalt and/or cobalamin is a contraindication to injections containing B12.
    • Vitamin B12 is contraindicated in Leber’s disease, a hereditary optic nerve atrophic condition, as it can lead to blindness.

    Potential Alternatives of IM Therapy include but are not limited to:

    • No treatment.
    • Oral supplementation of nutrients.
    • Transdermal application of certain substances such as B12 patches.
    • Dietary and lifestyle changes.

    By signing this form you acknowledge that you understand and agree to the following with respect to IM Therapy:

    • I am aware that unforeseeable complications could occur, and I do not expect the Registered Nurse of DripLife IV providing the IM Therapy to anticipate all possible complications.
    • Additionally, I understand that any possible side effects from the IM Therapy are best dealt with as they arise, and that it is my responsibility to inform the Registered Nurse providing the IM Therapy immediately if I feel any discomfort or sensation that is unusual.
    • I understand that the nature and purpose of IM Therapy may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered by some physicians to be medically unnecessary and not the standard of medical care for most conditions.
    • Non-FDA EVALUATED OR APPROVED. I understand and acknowledge that the United States Food and Drug Administration has not evaluated or approved the treatments I am about to receive to diagnose, treat, cure, or prevent any disease.

    No Insurance Coverage: I understand this procedure is not covered by insurance and I am responsible for total payment to DripLife IV for all such treatments.

    No Guarantees: I understand that each patient responds differently to treatments and from one treatment to the next. I understand results are only temporary and regular dosing is necessary. I understand the length of time IM Therapy is needed for therapeutic benefit varies for each patient. I further understand that no guarantee can be made or is made by Deacon Medical Corp. or DripLife IV LLC with respect to results and length of time required for IM Therapy benefit.

    Complete Medical Information:

    • I understand that IM Therapy may be contraindicated if I have certain medical conditions, allergies and/or take certain medications.
    • I have truthfully and accurately disclosed all personal medical information including but not limited to: all of my health conditions, my use of all medications, herbs, vitamins, and other supplements; and all known allergies to drugs or other substances or any past reactions. I understand that failure to do so may negatively affect my treatment outcome and the safety of the IM Therapy.

    Notice to All Female Clients Capable of Conceiving: I certify that I am not currently pregnant or breastfeeding.

    By signing this Informed Consent for Intramuscular Nutrient Therapy, I confirm and agree that:

    • I have read this entire Informed Consent, or someone has read it to me, and I understand and agree to the information herein.
    • The nature of the IM Therapy and the potential risks, benefits and alternatives have been explained to me, and I have had the opportunity to ask questions about the procedure and all my questions have been answered to my satisfaction.
    • I understand that this treatment may involve risks and complication as explained in this consent, and I hereby voluntarily accept all risks associated with IM Therapy and elect to proceed with treatment.
    • I hereby give my informed consent to participate in IM Therapy with a Registered Nurse of Deacon Medical Corp. dba DripLife IV under the supervision of Dr. Deacon Farrell MD.