IV Infusion, Injection, and Nebulized/Inhaled Therapy Consent Form

This form outlines that you understand that a peripheral intravenous catheter will be inserted into a vein in your body, and you will have fluids, vitamins, minerals, nutrients, and/or medications infused directly into your body. This is considered “IV Infusion Therapy.” If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.” If you are having nebulized or inhaled therapy, then you understand that medication (which may include a bronchodilator such as Albuterol and/or Ipratropium) will be delivered as a mist that you breathe in through a nebulizer mouthpiece or mask, rather than through a needle or catheter. This is considered “Nebulized/Inhaled Therapy.”

Purpose of Treatment:

I understand that Emet Drip Co offers different types of formulations. Some are provided for general wellness, hydration, or nutritional support. Others are symptom-targeted formulations intended to provide relief for an acute condition. My treating clinician will determine which type of formulation, if any, is appropriate for me today, and I may receive either or both types. The following applies to whichever type of formulation I receive:

• If I receive a general wellness/hydration formulation, I understand that it is intended for general wellness, hydration, or nutritional support. It is not intended to diagnose, treat, cure, or prevent any specific medical condition or disease, and any wellness claims made about it have not been evaluated by the US Food and Drug Administration (FDA). I understand that this type of formulation is not FDA-approved for any indication and is not considered a medical necessity.
• If I receive a symptom-targeted/acute-condition formulation, I understand that it contains FDA-approved medications (such as an antiemetic, an NSAID, an antihistamine, a bronchodilator, or similar) used for their approved purpose to provide symptomatic relief of an acute condition (such as nausea/vomiting, dysmenorrhea, migraine, acute GI upset, or bronchospasm) based on my treating clinician’s assessment. I understand that this treatment addresses my symptoms during today’s visit, does not establish an ongoing diagnosis, and does not treat, cure, or manage any underlying chronic condition. It is not a substitute for follow-up with my primary care provider or any specialist.
• I understand that Emet Drip Co is not an emergency medical provider. If my symptoms are severe, worsening, or do not respond to treatment, I will seek emergency care rather than relying on this treatment.
• I understand that whether any treatment I receive is considered medically necessary for insurance purposes is determined by my insurance plan, not by Emet Drip Co, and that Emet Drip Co does not guarantee coverage or reimbursement.

Please review each remaining point below:

• I have informed the Emet Drip Co registered nurse or nurse practitioner of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all of my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.
• I understand that I am here seeking treatment voluntarily and have been informed of the procedure involving IV infusion, injections, and/or nebulized/inhaled therapy, the alternative treatment options, and the risks and benefits of the mutually agreed upon treatment.
• I understand that the procedure involves inserting a needle into a vein, having a solution injected into my muscle or body fat, or breathing in a nebulized medication mist through a mouthpiece or mask, depending on the treatment ordered.
• I understand that common risks involved with IV and injection therapies include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the IV insertion or injection.
• I understand that less common risks involved with IV and injection therapies include, but are not limited to, infection at the site of the IV insertion or injection, injury to the tissue, phlebitis, low blood pressure, fainting, fluid volume overload, medication interactions, and drops in blood sugar levels.
• I understand that rare side risks involved with IV and injection therapies include, but are not limited to, sepsis, severe allergic reactions, severe medication/supplement interactions, anaphylaxis, blood clots, shock, cardiac arrest, and death.
• I understand that common risks involved with nebulized/inhaled therapy (such as nebulized Albuterol/Ipratropium) include, but are not limited to, rapid or irregular heartbeat (tachycardia), tremor or shakiness, nervousness or jitteriness, palpitations, headache, dizziness, dry mouth or throat irritation, and cough.
• I understand that less common risks involved with nebulized/inhaled therapy include, but are not limited to, paradoxical bronchospasm (a sudden worsening of breathing or wheezing immediately after treatment, which requires stopping the treatment and prompt evaluation), significant elevation in heart rate or blood pressure, and, if the medication mist contacts the eyes, temporary blurred vision, eye pain, or worsening of narrow-angle glaucoma.
• I understand that rare risks involved with nebulized/inhaled therapy include, but are not limited to, severe allergic reaction, worsening of urinary retention, significant cardiac arrhythmia, and, in patients with underlying cardiovascular disease, serious cardiovascular events.
• I understand that the benefits of IV and injection therapies include, but are not limited to, enhanced absorption of vitamins and minerals as they bypass the digestive tract, increased total body hydration, alleviation of certain symptoms, increased total body nutrient density, and improved performance/recovery.
• I understand that the benefits of nebulized/inhaled therapy include, but are not limited to, rapid delivery of medication directly to the airways to help relieve symptoms such as wheezing, chest tightness, or shortness of breath.

Emet Drip Co