Consent for IV Therapy

Informed Consent to Intravenous Hydration and Nutrient Therapy

The purpose of this Informed Consent to Intravenous Hydration and Nutrient Therapy (IV Therapy) is to obtain your consent to the IV 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 ,IV Therapy as well as the availability of alternatives, that you have had a chance to ask questions about IV Therapy, and that you voluntarily consent to the treatment.

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

IV Therapy Procedure

• 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.
• IV 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 IV Therapy depend on the substance(s) being infused. Such benefits include but are not limited to:

• Nutrients infused into the bloodstream are 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 IV Therapy include but are not limited to:

• Discomfort such as redness, bruising, swelling, burning, stinging, pain, and/or bleeding at the site of the infusion. The redness and swelling may last up to a few days.
• Inflammation, soreness and/or swelling of the vein used for the IV Therapy infusion, including phlebitis.
• Temporary metabolic disturbances such as temporary changes in blood sugar, temporary changes in blood pressure leading to lightheadedness or dizziness and/or increased thirst.
• Infiltration or leaking of the IV Therapy solution into surrounding tissue.
• Infection at the site of the infusion.
• Injury to nerve and/or muscle at the site of the infusion.
• Sensitivities or allergic reactions to the IV Therapy solution which could include, as any allergic reaction, anaphylaxis, cardiac arrest and death.

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

• Known liver and/or kidney dysfunction
• Known heart disease
• G6PD Deficiency
• Pregnancy

Potential Alternatives of IV 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 IV Therapy:

• I am aware that unforeseeable complications could occur, and I do not expect the Registered Nurse of DripLife IV providing the IV Therapy to anticipate all possible complications.
• Additionally, I understand that any possible side effects from the IV Therapy are best dealt with as they arise, and that it is my responsibility to inform the Registered Nurse providing the IV Therapy immediately if I feel any discomfort or sensation that is unusual.
• I understand that the nature and purpose of IV 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 IV 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 IV Therapy benefit.

Complete Medical Information:

• I understand that IV 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 IV 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 Intravenous Hydration and 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 IV 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 IV Therapy and elect to proceed with treatment.
• I hereby give my informed consent to participate in IV Therapy with a Registered Nurse of Deacon Medical Corp. dba DripLife IV under the supervision of Dr. Deacon Farrell, MD.