AI WELLNESS CENTER OF EXCELLENCE
INTRAVENOUS (IV) THERAPY CONSENT & AUTHORIZATION
This consent form confirms that I have been informed about intravenous (IV) therapy, including its purpose, potential benefits, limitations, risks, alternatives, and my responsibilities as a patient. This information allows me to make an informed and voluntary decision regarding IV therapy at AI Wellness Center of Excellence.
DESCRIPTION OF IV THERAPY
I understand that IV therapy involves the administration of fluids, vitamins, minerals, amino acids, antioxidants, and other nutrients directly into a vein.
I understand that IV therapy allows nutrients to bypass the gastrointestinal tract, potentially improving bioavailability and cellular uptake.
I understand that IV therapy may include, but is not limited to, the administration of vitamins (including Vitamin C, B-complex, B12, and others), minerals and electrolytes (including magnesium, zinc, calcium, selenium), antioxidants (including glutathione), amino acids, NAD+ and NAD-related compounds, trace elements, and other injectable nutrients or compounds deemed appropriate by my provider.
I understand that additional vitamins, minerals, antioxidants, amino acids, or wellness compounds not specifically listed above may be used based on clinical judgment, availability, and individualized protocols.
INTENDED BENEFITS (NO GUARANTEES)
I understand that IV therapy may be used to support hydration, nutrient repletion, energy and recovery, immune and inflammatory balance, oxidative stress reduction, metabolic and cellular function, and general wellness and performance.
I understand that individual responses vary, results are not guaranteed, and medicine and wellness therapies are not exact sciences.
LIMITATIONS & MEDICAL DISCLAIMER
I understand that IV therapy is not a guarantee of symptom resolution, performance enhancement, or disease improvement.
I understand that IV therapy is not a substitute for primary medical care, emergency care, or specialist treatment.
I understand that payment is for the professional service rendered, not for a guaranteed or patient-determined result.
TREATMENT FREQUENCY
I understand that treatment frequency varies based on individual needs and protocols and may range from occasional use to periodic or series-based therapy.
I understand that multiple treatments may be required to achieve or maintain desired wellness support.
OPTIONAL ADJUVANT THERAPY: WEBER LOW LEVEL LASER THERAPY (LLLT)
I understand that Weber Low Level Laser Therapy (LLLT), also known as photobiomodulation, may be offered as an optional adjunctive therapy during IV treatment.
I understand that Weber LLLT uses low-intensity, non-thermal laser light delivered via optical fiber to interact with circulating blood components during infusion.
I understand potential supportive benefits may include support of mitochondrial and cellular energy function, circulation and oxygen utilization, redox balance and oxidative stress modulation, immune and inflammatory balance, recovery, and resilience.
I understand that Weber LLLT does not alter the chemical composition of the IV solution and is not intended to diagnose, treat, cure, or prevent disease.
WEBER LLLT CONTRAINDICATIONS & PRECAUTIONS
I understand Weber LLLT may not be appropriate in certain situations, including but not limited to active or suspected malignancy without physician clearance, photosensitivity disorders or use of photosensitizing medications, pregnancy or breastfeeding, uncontrolled seizure disorders, implanted electronic medical devices, and acute unstable medical conditions.
I understand my provider may decline or discontinue this adjunct therapy at their discretion.
RISKS & POSSIBLE SIDE EFFECTS
I understand that IV therapy carries potential risks, including but not limited to discomfort, bruising, or tenderness at the IV site; phlebitis; swelling or infiltration; infection; lightheadedness or fatigue; allergic reactions including rare anaphylaxis; cardiac arrhythmia; and serious adverse reactions including hospitalization or death.
I understand that unknown or unanticipated side effects may occur.
PREGNANCY & BREASTFEEDING
I understand that the safety of IV therapy and adjunctive treatments during pregnancy or breastfeeding has not been established.
PATIENT RESPONSIBILITIES
I agree to disclose all medical conditions, medications, supplements, allergies, and health changes.
I understand it is my responsibility to notify the clinic immediately if I experience adverse symptoms during or after treatment.
I agree to allow AI Wellness Center of Excellence the opportunity to evaluate and manage complications before seeking outside care when appropriate.
FINANCIAL & REFUND POLICY
I understand that there are no refunds for patient-determined unsatisfactory results.
I understand that payment is for services rendered, not for a guaranteed outcome or longevity of effect.
PROVIDER AUTHORIZATION
I hereby authorize Dr. Gideon Kwok, D.O., and/or trained and qualified medical associates to administer IV therapy and any elected adjunctive therapies.
I acknowledge that I have had the opportunity to ask questions regarding provider qualifications and am satisfied.
VOLUNTARY CONSENT
I confirm that the procedure has been explained to me, alternatives have been discussed, risks and limitations are understood, and I am consenting voluntarily and without coercion.
FINAL ACKNOWLEDGMENT
I certify that I have read, understood, and agree to the contents of this IV Therapy Consent. I understand this form supersedes all prior verbal or written disclosures.
