You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent.
- The procedure involves inserting a needle into your vein or muscle and injecting the formula described above by your provider.
- Alternatives to intravenous therapy is oral supplementation and/or dietary and lifestyle changes.
- Risks of intravenous therapy include:
  1. Discomfort, bruising, and pain at the site of injection.
  2. Inflammation of the vein used for injection, phlebitis.
  3. Severe allergic reaction, anaphylaxis, cardiac arrest and death.
- Benefits of intravenous therapy include:
  1. Injectables are not affected by stomach or intestinal disease.
  2. Total amount of infusion is available to the tissues.
  3. Nutrients are forced into the cells by means of a high concentration gradient.
  4. Higher doses of nutrients can be given than possible by mouth without intestinal irritation.
You have the right to consent to or refuse the proposed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent to the procedure(s) described above.
The procedure will be performed by qualified registered nurses.
Your signature below means that:
- You understand the information provided on this form and agree to the foregoing.
- The procedure(s) set forth above has been adequately explained to you by your provider.
- You have received all the information and explanation you desire concerning the procedure.
- You authorize and consent to the performance of the procedure(s).