IM Therapy Consent Form This document is intended to serve as confirmation of informed consent for IM therapy as ordered by Dr. Robert Maccani DO. I have informed the doctor of all current medications and supplements. I have also informed Dr. Robert Maccani and staff of any known allergies to drugs or other substances, or of any past reactions to anesthetics. I understand that I have the right to be informed of the procedure, any alternative options, and the risks and benefits of IM therapy. Procedures will not be performed until I have the opportunity to give my informed consent. My signature below acknowledges that: 1. This procedure involves inserting a needle into the muscle and injecting a prescribed solution. 2. Alternatives to IM therapy include, but are not limited to, oral supplementation. 3. The potential risks of IM therapy include, but are not limited to: I. Occasionally: Discomfort, bruising and pain at the injection site. II. Rarely: Inflammation of the muscle used for injection, metabolic disturbances, and injury. III. Extremely rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death. 4. Benefits of IM therapy include: I. IM medications are not affected by stomach, or intestinal absorption disturbances. II. The total amount of medication/nutrients is available to the tissues (100% bioavailability). III. Higher doses of nutrients are able to given to the body than through oral consumption and absorption. I am aware that unforeseeable complications could occur, and I do not expect Dr. Robert Maccani to anticipate or explain all possible complications. I rely on the doctor to exercise judgement during the course of my treatment. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent or refuse any proposed treatment at any time. My signature affirms that I have given consent to IM therapy with Dr. Robert Maccani DO. I understand that all nutrient infusions are considered investigational/experimental and are not considered standard of care. My signature below confirms that: I am giving informed consent and I have read this consent form and understand the information contained in it. I understand the risks and benefits and have had the opportunity to have all my questions answered to my satisfaction. I am aware that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and explain all risks and possible complications. I rely on the provider(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions were answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I give my consent to IM nutrient therapy. I have given a full medical history and have updated my medical history to staff upon appointment. What safety precautions must you take? ● Before this and every IM/IV treatment I will inform Collagen Aesthetics if I have any of the following: kidney or liver disease, any infection, iron deficiency, Leber’s disease, history of gout, polycythemia versa (blood disorder), taking methotrexate, cobalt or sulfa allergy ● Monitor the insertion site for signs and symptoms of infection (redness, swelling, discharge). Notify the clinic immediately. If you experience a sustained fever greater than 101, do not delay treatment and go to the ER as this can be a sign of sepsis. ● If you experience a minor side effect while you are at home you should contact the front desk at 810-845-6964, otherwise contact your medical provider or call 911. _______________________________ (Patient’s Signature) _________________ Date ____________________________ (Signature of Collagen Aesthetic Staff) ________________ Date www.collagenaesthetics.net Dr. Robert Maccani Please note that before beginning IM therapy, records of the following tests are recommended: • Complete Blood Count (CBC), Renal Function, Electrolytes. • Urinalysis (dipstick).
