INTRAVENOUS MICRONUTRIENT THERAPY CONSENT FORM

PATIENT INFORMATION:

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Intravenous micronutrient therapy is the introduction of supplemental micronutrients into the body through the veins. The purpose of this treatment is to promote natural beauty by providing only the most exclusive cutting-edge supplement products, while at the same time improving the body’s state of health. This form of therapy ensures the body gains the full benefits of the infused micronutrients as they are absorbed directly into the bloodstream.

All our intravenous procedures are carried out by trained medical professionals utilizing the appropriate Aseptic Non-Touch Techniques (ANTT) and appropriate pre and post care is taken in the administration of the micronutrient supplements.

At The Abram, we use quality products that ensure optimal results. In the course of your treatment, it is normal that we may need to administer a top up (booster) infusion of the vitamins or micronutrients. A custom treatment plan will be formulated per client to ensure achievement of set goals within agreed timelines.

The frequency of treatment will vary depending on the products that will be used as well as the purpose of the treatment. All our infusions consist of nutrients already present in the food that we consume. This guarantees safety and it is rare for one to experience adverse reactions after any of our treatment options.

CONSENT TO INTRAVENOUS MICRONUTRIENT THERAPY

Tick the check box to agree

I am aware that I have the right to be informed of the risks and benefits of the procedure. Except in emergencies, procedures are not performed until I have had the opportunity to receive information regarding the procedure and to give my informed consent.

I acknowledge the fact that intravenous micronutrient supplementation is designed to achieve optimum health, absent of other non-nutritional complicating factors, and requires commitment, possible lifestyle changes, and a positive attitude. It is not intended for medical diagnosis or treatment

I understand that if I have any pre-existing medical condition, I need to consult with an appropriate health care provider and it’s important that I inform my other healthcare providers about my use of nutritional supplements.

I understand that if am using medications of any kind, I need to consult with my pharmacist of any potential interactions between medications and nutritional products.

I am aware that if I develop any adverse reactions, I should discontinue use immediately.

I understand that the procedure involves: invasive insertion of medical devices, several sessions may be required, common risks include: pain, bruising, discomfort, inflammation, phlebitis and rare risks include (requiring medical consultation): infection, anaphylaxis or air embolisms.

I am aware that unforeseeable complications may occur despite The Abram anticipating or explaining all risks and possible complications. I rely on them to exercise judgment during the course of treatment with regards to my procedure.

I am aware that I will be asked to stay for 30 minutes after the procedure for monitoring of potential side effects such as nausea, lightheadedness and/or allergic reactions.

I understand that at any point of the infusion I have a right to terminate the procedure, without being reimbursed.

I certify that I have read or have had my practitioner read to me all the contents of this form. I understand the risks and alternatives involved in the performance of this procedure(s). In addition, I have had the opportunity to ask questions and can confirm all my concerns have been addressed. I acknowledge that I have reviewed and approved the material given to me and I authorize The Abram, as my practitioner to perform the intravenous micronutrient supplement therapy desired today.

This is your medical history form, to be completed prior to your infusion treatment. Intravenous micronutrient supplements are not treatment indicators for medical conditions. All information provided will be kept confidential and will only be used for the evaluation of your health and suitability for your infusion program. Pictures or Videos will be obtained for medical records. If they are used for education and marketing purposes, all identifying marks will be cropped or removed.

Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature:

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Date / Time

Infusion Type

PRE AND POST TREATMENT CARE

Hydration: You will be required to drink plenty of water before the procedure in order to improve the visibility of veins and after the procedure to provide optimal results.

Monitoring of vital signs: Your blood pressure and pulse will be taken before and after the procedure. If need arises, they will also be taken during the procedure.

Rest: A thirty minutes’ rest is necessary after administration of intravenous micronutrients supplements because of the potential side effect of lightheadedness/dizziness.

Maintenance: You will be advised to maintain the vitamins and micronutrients levels in the body through, supplementation with oral pills, good vitamin-based products and top up with booster or drip as needed.

POSSIBLE RISKS AND COMPLICATIONS

Pain: Some level of pain is expected when the intravenous needle is inserted in the vein. You may feel a small sting or pinch on either the hand or arm where the needle is inserted. Pain levels vary depending on the pain receptors and the individual pain thresh-hold.

Superficial phlebitis: Inflammation of a vein often caused by an intravenous catheter placed in a vein, hence the vein becomes irritated. This will be avoided by choosing the proper insertion site, the right needle and securement technique.

Skin breakout/rash: Your skin may break out after the infusion because of the body’s attempt to get rid of toxins(detoxification) or due to the high level of vitamin C administered. Vitamin C sometimes acts as a free radical which damages the cells of the skin.

Nausea: Glutathione is an anti-oxidant with strong antiviral properties; most antivirals irritate the gastrointestinal system hence resulting in symptoms such as nausea.

Lightheadedness: You may feel light-headed after the infusion procedure that’s why hydration and a thirty minutes’ rest are recommended.

Infection: You will be protected from IV site infection through the use of Aseptic non-touch technique in performing the procedure.

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INTRAVENOUS MICRONUTRIENT THERAPY CONSENT FORM

PATIENT INFORMATION:

CONSENT TO INTRAVENOUS MICRONUTRIENT THERAPY

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