Informed Consent for Intravenous Therapy
Sun and Sea IV LLC

 

This document serves as confirmation of informed consent for IV therapy administered at Sun and Sea IV.  

 

  • I have informed the provider of any known allergies to drugs, supplements, or other substances, or of past reactions to anesthetics. I understand that the sole risk of injury or harm that results from any participation in intravenous supplement administered by Sun and Sea IV rests solely with me insofar as to the extent to which I do not disclose those allergies in advance.

  • I have informed the provider of all current medications and supplements and understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with me in so far as to the extent to which I do not disclose my health conditions, medications, or supplements in advance.

  • I have informed the provider of all medical conditions, diseases, and illnesses. I attest that I have never been diagnosed with or treated for any such conditions that would put me at increased risk while receiving IV services by Sun and Sea IV. I understand that I will be screened for said conditions prior to initiation of services.

  • I understand that I have the right to be informed of the risks and benefits before therapy administration. No procedures will be performed until I have had an opportunity to receive such information and to give my informed consent. Sun and Sea IV therapies are not intended for emergency care. The intravenous procedure involves inserting a needle into the vein and infusing supplements intravenously. Time will vary depending on your anatomy and infusion rate, however the therapy should be expected to take about 30 to 60 minutes.

  • I understand that IV therapy carries with it both risks and benefits. Some of those risks and benefits include, but are not limited to:

I understand that in the practice of IV therapy there are some risks of examination and treatment and that the following possible complications could occur, although they are very unlikely:

Discomfort, soreness, bleeding, bruising, pain and possible scarring at the site of injection. Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. Lightheadedness or fainting. Severe reaction to medication, supplement or vitamin therapy; anaphylaxis, cardiac arrest or death. Volume overload. Air embolism. Infiltration. Injectables are not affected by stomach or intestinal disease. Total amount of infusion enters the bloodstream and is available to the tissues. Higher doses of nutrients can be given intravenously than can be ingested orally. Can be used in conjunction with oral supplements, diet, exercises & other lifestyle modifications. 

  • I am aware that other unforeseeable complications could occur. I understand the risks and benefits of intravenous supplements 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 supplement administration at any time before or during its performance. My signature on this form affirms that I have given my consent to receive intravenous supplements in conjunction with any procedure and or medication, as prescribed by my physician.  I understand that services offered by Sun and Sea IV LLC are not intended to replace prescription medications, diagnose, treat or cure medical conditions.

  • I attest that I am not under the influence of illegal drugs or substances at the time of supplement administration. I agree that I am not using Sun and Sea IV supplements to recover from any drug related symptoms. I understand that if any suspicion of such is made by the provider, my right to therapy administration will be waived and will not be subject to a refund.

  • I understand that a record of my vitamin infusion will be generated with each visit. We are committed to your privacy and all health care information provided to Sun and Sea IV will be protected. Any disclosures of protected health information will therefore require authorization, unless used in the following ways:

    • Quality improvement regarding Sun and Sea IV.  Health related benefits and services referral. Any court ordered requests or subpoenas. Any law or government mandates with appropriate warrant

  • I understand the information provided on this form and agree to all therein. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. I understand that I am free to withdraw my consent and discontinue participation in their supplement administration at any time.

  • Once submitted this form is good for 6 months or until a medical change is reported to Sun & Sea IV staff