This document is intended to serve as confirmation of informed consent for intravenous therapy (IV) as ordered by the medical director of Race IV | Recovery Solutions. I agree that I made the decision to receive intravenous hydration and various additives of my choosing. I understand that I have the right to be informed during the procedure, and the risks and benefits. I understand that if an emergency condition exists, Race IV team members will contact emergency services and stay with me until their arrival. I understand thatprocedures are not performed until I have had an opportunity to receive such information and to give my informed consent by signing below. I also understand that all infusions are under the direction of the Race IV | Recovery Solutions Medical Director, Dr. Raymond Brewer, MD and there are various reasons Race IV will not be able to provide my infusion. This includes outlined exclusionary past medical history, medical emergency and descretion of the medical director.
The intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals).
I understand that risks, benefits and alternatives to IVs may include but are not limited to:
1. The Risks and potential side effects
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Discomfort, bruising, and pain at the site of injection.
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Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
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Severe reaction, anaphylaxis, cardiac arrest, or death.
2. The Benefits
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lnjectables are not affected by stomach or intestinal disease.
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Total amount of hydration enters the bloodstream and ia available to the tissues
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Rehydration after a period of dehydration.
3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes.
I understand taht these statements are not approved by the FDA and are the opinion of Race Iv | Recovery Solutions. I have researched the components of the infusion and agree to continue with the infusion.
I am aware that other unforeseeable complications could occur. I do not except the medical team members to exercise judgement 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 questions answered. 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 with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
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. The procedure(s) set forth above Race IV | Recovery Solutions has been adequately explained to me the team and I have or decided to not consult with my physician prior to receiving the infusion. I understand that I am free to withdraw my consent and to discontinue participation in treatments at any time. I understand that, once registered and payment is completed, IV solutions will be prepared for me at the event and I will not receive a refund for the solutions if I change my mind. I understand that I will incur the full fee for treatment. regardless of amount used due to wasted materials.
I understand that a pressure dressing is applied after my infusion and if bleeding continues, I should hold pressure and seek medical attention if it is not controlled with holding pressure.
