IV THERAPY TREATMENT CONSENT

I. Purpose

This IV Therapy Treatment Consent (“Consent”) applies to patients receiving intravenous (IV) therapy services through the Evolve Your Bod Hybrid (Consult + IV) or Mobile IV care models. By signing this Consent, you acknowledge that you understand the risks, benefits, and procedures associated with IV therapy and agree to receive treatment as described below.

II. What Is IV Therapy?

IV therapy involves the administration of fluids, vitamins, minerals, medications, or other therapeutic formulations directly into your bloodstream through a needle or catheter inserted into a vein. IV therapy is ordered by a licensed physician and administered by a licensed clinical professional, such as a registered nurse (RN) or higher-level licensee.

III. Physician Order and Nurse Administration

You acknowledge and agree to the following regarding the ordering and administration of IV therapy:

– All IV therapy is administered pursuant to an order from a licensed physician affiliated with the rendering Medical Group.

– The physician ordering the IV therapy has reviewed your medical information, including allergies, medications, and health history, and has determined that IV therapy is clinically appropriate for you.

– The IV will be administered by a licensed registered nurse (RN) or higher-level clinical professional operating under the physician’s order and applicable delegation and supervision protocols.

– The administering nurse will verify your identity, confirm your allergies and current medications, review the IV formulation with you, and monitor you during and after administration.

IV. IV Formulations and Compounding

IV formulations administered through Evolve Services may include compounded preparations produced by licensed compounding pharmacies. You acknowledge:

– Compounded IV formulations are not FDA-approved and may differ from commercially manufactured products in formulation, testing, and quality assurance.

– The specific formulation, ingredients, and dosage of your IV therapy will be determined by your physician based on your clinical needs.

– You are responsible for disclosing all known allergies, medications, supplements, and medical conditions to your provider and the administering nurse before IV therapy begins.

V. Risks of IV Therapy

IV therapy carries inherent risks, including but not limited to:

– Pain, bruising, swelling, or discomfort at the insertion site.

– Infiltration (fluid leaking into surrounding tissue) or extravasation (irritating substances leaking into tissue).

– Phlebitis (inflammation of the vein).

– Infection at the insertion site or systemic infection.

– Allergic or adverse reactions to IV formulations, including anaphylaxis in rare cases.

– Air embolism (air entering the bloodstream).

– Fluid overload or electrolyte imbalance.

– Hematoma (blood pooling under the skin).

– Nerve injury at the insertion site.

– Vasovagal response (fainting or lightheadedness).

These risks are generally uncommon but can occur. Your administering nurse is trained to monitor for these complications and will follow established emergency escalation protocols if an adverse event occurs.

VI. Emergency Protocols

If you experience an adverse reaction during IV therapy:

– The administering nurse will immediately discontinue the infusion if clinically indicated.

– The nurse will follow established adverse event and emergency escalation protocols, which may include administering emergency intervention (such as epinephrine for anaphylaxis), contacting the ordering physician, and/or calling 911.

– You will be monitored until the situation is stabilized or emergency medical services arrive.

– An incident report will be documented and reported to the ordering physician and to Evolve Your Bod.

VII. Patient Acknowledgments

By signing below, electronically accepting this Consent through the Evolve Your Bod platform, clicking ‘I Agree,’ checking the associated consent box, or proceeding with IV therapy after being presented with this Consent, you affirm:

– I understand that IV therapy is administered under a physician’s order by a licensed clinical professional.

– I have been informed of the risks, benefits, and alternatives to IV therapy.

– I have disclosed all known allergies, medications, supplements, and relevant medical conditions to my provider and the administering nurse.

– I understand that IV formulations may include compounded preparations that are not FDA-approved.

– I understand the emergency escalation protocols and that 911 may be called if necessary.

– I have the right to refuse or discontinue IV therapy at any time.

– I have had the opportunity to ask questions about IV therapy and have received satisfactory answers.

– I consent to the documentation and sharing of my IV therapy records with Evolve Your Bod and the rendering Medical Group for care coordination purposes.

VIII. Contact Information

Evolve Your Bod (AA Health Solutions, LLC)

5521 Bellaire Drive South, Suite 200, Fort Worth, TX 76109

Email: info@evolveyourbod.com | Phone: 866-301-3141