IV Nutrition Therapy Informed Consent
Dee Warner, F.N.P
pureprimary care
260 S. 112th St
Lafayette, CO 80026
Dr. Lisa Amerine, ND
purehomeopathy
260 S. 112th St
Lafayette, CO 80026
Today’s Date
Patient Name:
Please Print
IV Nutrition Therapy is a powerful way to access cells, to accelerate healing, and
prevent infection. While the use of IV nutrients is safe, is some cases there can be
issues and complications. 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. By following our recommendations
below, we can minimize the complications and risks and ask that you follow the
guidelines for IV Therapy treatment.
 I (the patient) understand that before IV Nutrition Therapy, I must:
1. Complete lab work (CBC, Comp Metabolic Panel, MTHFR, G6PD, U/A);
2. Notify the Provider of all medications and supplements you are currently
taking, and current health issues you may be having.
3. Arrive to IV Therapy appointment hydrated – if dehydration occurs because of
the nutrient IV, you will be given fluids to correct the dehydration;
4. Arrive to IV Therapy appointment having eaten a meal or snack, or bring
snacks with you;
 Initials
 I (the patient) understand that the following will reduce the efficacy of IV Nutrition
Therapy and that it may take more treatments to reach optimal health:
 Cigarette Smoking;
 Certain medications;
 Caffeine consumption increases Vitamin C excretion;
 Poor diet: processed foods, high sugar intake, nutrient deficient diets;
 Heavy metal toxicity;
 Initials
 I (the patient) understand that having a IV Nutrition Therapy may stimulate the
immune system and detoxification pathways and this can cause symptoms such as
fever, fatigue, headaches, and nausea. Please contact us if you have concerns or
questions following your IV Therapy treatment.
 Initials
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 I (the patient) understand that the procedure will be performed by of the Healthcare
Provider(s) named above who are trained and certified in administering, monitoring
and ordering IV Therapies.
 The IV Therapy procedure involves inserting a needle into your vein or
muscle and injecting the formula described by your provider.
 Alternatives to IV Therapy are oral supplementation and/or dietary and
lifestyle changes.
 It may be recommended, depending on follow up tests to continue these
treatments from time to time to maintain health benefits.
 Initials
 I (the patient) understand the Risks of IV Therapy include:
 Possible fall in blood pressure which can be related to magnesium in the IV.
The provider will be present and able to help you by stopping the infusion
and/or providing some extra IV fluids to bring the blood pressure to normal.
 Discomfort, bruising and pain at the site of injection;
 Inflammation, infiltration or infection of the vein used for injection, phlebitis;
 Severe allergic reaction, anaphylaxis, cardiac arrest and death;
 Initials
 I (the patient) understand the Benefits of IV Therapy include:
 Injectable Nutrients are not affected by stomach or intestinal disease;
 Total amount of infusion is available to the tissues;
 Nutrients are forced into cells by means of a high concentration gradient;
 Higher doses of nutrients can be given than are possible by mouth without
intestinal irritation;
 Initials
 I (the patient) understand that IV Nutrition Therapy is not covered by insurance and
that PH will not bill your insurance of this service.
 I (the patient) understand that if I submit an insurance claim for the IV Nutrition
Therapy, that I will be responsible for any and all non-covered services.
 Initials
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 Your signature below means that:
1. You have read and understand the information provided in this form, had all your
questions answered, are knowledgeable about the conventional treatments
available for your condition, and are aware that the IV Nutrition Therapy is not
FDA approved and is considered “unconventional”. Long-term adverse
consequences of these therapies may be possible, but are unknown at this time.
By signing this consent, and agree to the foregoing.
2. The provider has adequately explained the IV procedure set forth to you.
3. You have received all the information and explanation you desire concerning the
procedure/
4. You authorize and consent to the performance of the procedure as agreed upon
with the Provider.
By signing this consent, I understand these risks, and I am willing to accept the risk. I
have been advised that this therapy may be beneficial in my condition. I understand the
benefits of this treatment will be enhanced by engaging in positive lifestyle changes
such as exercise, proper diet, and nutritional supplementation that has been
recommended by the Healthcare Provider.
 I,
,give my informed consent for
Intravenous Therapy to Dee Warner, FNP or Dr. Lisa Amerine, ND (who are trained
and certified in administering, monitoring and ordering intravenous therapies).
I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND ALL MY
QUESTIONS HAVE BEEN ANSWERED. I understand I should not sign this form if
Intravenous Vitamin Supplementation Therapy, its possible risks, and its possible
benefits have not been explained to my satisfaction. I further understand that I should
not sign this form if I have unanswered questions or if I do not understand anything in
the consent form.

Patient Signature
Print Name
Date Signed

Practitioner Signature
Print Name
Date Signed
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