Consent and Authorization:
INTRAVENOUS THERAPY PROCEDURES


Patient Information

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How did you hear about us?

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Procedure

IV Infusion
IV Injection
Other
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Infusionisttextoptional

Terms of Service

1. Salus Hydrate provides facilities and personnel to assist you in obtaining intravenous therapy. You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits of the procedure. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent

  1. The procedure involves inserting a needle into your vein or muscle and injecting a formula recommended by your physician and available for your review prior to administration.

  2. Alternatives to intravenous therapy include oral supplementation and/or dietary and lifestyle changes.

  3. Risks of intravenous therapy include:

    1. Discomfort, bruising, and pain at the site of injection

    2. Inflammation of the vein used for injection, also called phlebitis

    3. Severe allergic reaction, anaphylaxis, cardiac arrest, and death

  4. Benefits of intravenous therapy include:

    1. Injectables are not affected by stomach or intestinal disease

    2. The total amount of the infused nutrients is available to the tissues by forcing them into cells through a high concentration gradient

    3. Higher doses of nutrients can be given than possible by mouth without intestinal irritation

2. You have the right to consent to or refuse any proposed treatment at any time prior to or during its administration. Your signature below affirms that you have given your consent to the procedure(s) described above.


My signature below means that:

  1. I understand the information provided on this form and agree to the foregoing.

  2. The procedure(s) listed above have been explained to me in detail and I understand the risks and benefits of undergoing this treatment.

  3. I have received all the information and explanation I desired concerning the proposed procedure(s).

  4. I authorize and consent to the performance of the procedure(s).


Acknowledgement of Non-Insurance Coverage for Services Rendered

I agree, and it has been explained to me, that the following services being performed are not generally considered and accepted for reimbursement by my health insurance provider:

  • IV/injection services and supplies

  • Any supplements such as botanicals, homeopathies, nutraceuticals, etc.

  • Other supplies such as tape, bandages, tubing, etc.

I will not seek reimbursement from my insurance company nor will I expect Salus personnel to assist me in filing claims for these services. This includes Evaluation and Management (or other medically necessary services), IV/injection services and supplies, and/or supplements and other supplies.

I understand that this requires my payment in full for all IV/injection services, supplies, supplements.

My signature below acknowledges that I understand all of the above and that I will not attempt to submit claims for these services to my insurance provider or other payers.

Date: 1/4/2019

Time: 8:45 AM


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Parent/Legal Guardian

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