This document is a binding agreement (the “Agreement”) between The Revive Room LLC DBA Intra-V (“We” or “Us”), and the individual patient whose name and signature appears below (“You” or “Your”). In consideration of the health care services provided to You by Us at the present and at all times in the future, You agree as follows;
Consent for Treatment. You hereby authorized Us to provide You with health care treatment, including without limitation medical, diagnostic, nutritional treatment, (together the “Treatment”) administered by Us, physicians, or assistants. You understand that the practice of health care/ medicine is not an exact science and that diagnosis and treatment may involve risk of injury or death. You acknowledge that we have not made any guarantees or promises as to the outcome or the safety and efficacy of the Treatment.
Experimental Nature of Treatment. You acknowledge and agree that the evaluation, diagnosis, and treatments may consist in whole or part of experimental procedures and methods, including without limit Intravenous Micronutrient Therapy, Ozone Therapy, PEMF Therapy, Prolotherapy, and Mesotherapy, on which no governmental (including the U.S. Food and Drug Administration (“FDA”)), scientific or medical authority has issued any guidelines or statements as tot he safety or efficacy thereof. You acknowledge that the safety record of the Treatments is based only on empirical and anecdotal evidence, which only shows that the Treatments appear to be relatively safe. We have informed you that the Treatments MAY alter, address, or decrease your pain, symptoms, or complaints, but also may have no effect.
Risks, Side Effects, Complications. We hereby inform You that there are certain unavoidable risks and potential side effects and complications to the Treatments, including without limitation infections; swelling; increased pain; bleeding; scarring; scar or wound enlargement; keloid formation; asymmetry; temporary or permanent alteration in sensation; allergic reaction; discoloration; the need for additional surgery; soreness, itching, infection, injury to nerves, internally and externally leaking fluid and scarring at injection sites (all of which except the leaking of fluid may be permanent); a feeling of “lumpiness” or permanent skin contour irregularities at the site of Treatments; spinal cord injuries, Pneumothorax (air on the outside of the lung), paralysis, dizziness, numbness, no benefit from Treatments; or other serious or debilitating injuries or death.
Description of Treatments. You acknowledge that the Treatments may involve insertion of needles into your skin and veins and the injection of standardized formulas which may include various nutritional substances, homeopathic medicines, and FDA approved prescriptive medicines, local anesthetic (Procaine or Lidocaine), concentrated sugar water or dextrose, and, on occasion ozone therapy and local subcutaneous anesthetic infiltration. The exact solution and site of injection for Your Treatment, as well as the recommended sequence of Treatments, will be explained to You when We actually administer the Treatments.
Health Care Staff. You are aware that among those who attend You on Your behalf are medical, nursing, and other health care personnel in training, who unless requested otherwise, may participate in patient care as part of their education. You further consent to the presence of service representatives and/ or technicians from manufacturers of equipment or devices to assist in performing and/or operation of such equipment and/or devices during operation, procedures, and Treatments. These workforce members have signed confidentiality agreements with us.
Information You Provide Us. You have provided Us with a complete list of all prescription and non-prescription medications and dietary supplements You are currently taking, and You agree to update Us periodically should this list change. You have provided us with a complete list of all known allergies You may have, and all allergic or adverse reactions You have had in the past to any medicines, dietary supplements or medical treatments of any kind. You covenant that all the information You provide Us during the course of Treatments, including without limitation the information required by this Section 6, is true, accurate, complete, and up-to-date to the best of Your knowledge.
Assumption of Risk. You hereby acknowledge that after having read carefully and understood fully the terms of this Agreement, and after having adequate time to ask any questions about this Agreement or the Treatments that you have, you are willing to assume any and all risks associated with the Treatments, including without limitation those described in this Agreement. You acknowledge that no explanation or description of the Treatments can ever be fully explain every possible risk, side effect, or complication that may or could arise from the Treatments, but that by signing this Agreement, You nevertheless acknowledge Your willingness to assume such risks and that Your consent to the Treatment s is willing, voluntary, and informed.
Miscellaneous. You agree that this Agreement constitutes the entire agreement between You and Us regarding the subject matter hereof. No promise, representation, guarantee or warranty not included in this Agreement has been or is being relied upon by You. This Agreement shall be binding on You and Your successors, heirs, legal representatives and assigns. In case any one of the previsions of this Agreement is held invalid or illegal, such provisions shall be curtailed, limited or severed only to the extent necessary to remove such illegality or invalidity. This Agreement shall be governed by the laws of the state of Idaho without regard to any choice of the law principal. Any dispute between You and Us shall be adjudicated in state or federal court in Idaho Falls, Idaho, and You submit to the jurisdiction of any such court.
This document is intended to serve as a confirmation of informed consent for compounded Semaglutide, which is a prescription weight management medication.
A. Patient Informed Consent
1. I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
2. I have the right to be informed of any alternative options, side effects, and the risks and benefits.
3. I understand the mechanism of action of the medication.
4. I understand how it is to be administered.
5. I understand the prescription may come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
6. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
7. I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.
Common side effects include, but are not limited to:
· Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase
· Neurological: Headache, dizziness
· Cardiac: Heart rate increase, Hypotension
· Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
· Ophthalmic: Retinal disorder (diabetic patients)
· Skin: redness or pain at injection site
Serious Reactions include, but are not limited to:
· Thyroid C-cell tumor (animal studies)
· Medullary thyroid cancer
· Hypersensitivity reaction
· Anaphylaxis
· Angioedema
· Acute kidney injury
· Chronic renal failure exacerbation
· Pancreatitis
· Cholelithiasis
· Cholecystitis
· Syncope
Do not take this medication if:
· You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer). Multiple Endocrine Neoplasia syndrome type 2.
· You are pregnant or plan to become pregnant while taking this medicine.
· You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist. Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.
· You have a history of Pancreatitis.
· You are allergic to NAD+, Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®; If you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems.
Possible drug interactions:
Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® (THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.
B. I understand that I have the following responsibilities:
1. I agree to obtain prescriptions for compounded semaglutide only from The Revive Room LLC, DBA Intra-V
2. Medical history: I will inform The Revive Room LLC, DBA Intra-V of my complete medical history, including: allergies, medications, medical/surgical/social/family history.
a. I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.
b. I will be honest to the best of my ability the history she needs to know.
c. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
d. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider
e. I will always tell other providers about all medications I am taking.
f. The Revive Room LLC DBA Intra-V may ask for me to seek additional labs while on treatment to ensure it’s safety.
3. Discontinuation of medication: I understand that The Revive Room LLC, DBA Intra-V may stop prescribing my medications if:
a. I am having unfavorable side effects or it’s not working to treat my medical condition
b. I have been untruthful in my medical or family history
c. I do not follow through with the recommended plan of care set by The Revive Room LLC DBA Intra-V.
d. I do not follow any parts of “Part B: responsibilities” in this agreement.
I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.
WAIVER AND RELEASE OF LIABILITY FOR RED LIGHT THERAPY BED
I understand that the use of the Red Light Therapy Bed at Intra-V may involve risks, including but not limited to temporary skin irritation, burns, photosensitivity reactions, or eye damage if appropriate precautions are not followed. I acknowledge these risks and choose to voluntarily participate in red light therapy sessions.
I understand that red light therapy is not intended to diagnose, treat, cure, or prevent any medical condition. I acknowledge that it is my responsibility to consult with my healthcare provider before using the red light therapy bed, particularly if I have any pre-existing medical conditions, am pregnant, am sensitive to light, or am taking medications that may increase light sensitivity.
I acknowledge that results from red light therapy vary from person to person and that Intra-V makes no specific promises regarding the outcome of this treatment for my particular condition or purpose.
I agree to use protective eyewear provided during each red light therapy session to protect my eyes from potential harm.
In consideration of being allowed to use the red light therapy bed at Intra-V, I hereby release, discharge, and hold harmless Intra-V, its owners, staff, employees, agents, and representatives from any and all liability, claims, demands, actions, or causes of action arising from any injury, loss, or damage sustained during or as a result of my use of the red light therapy bed, whether caused by negligence or otherwise. I agree to indemnify and hold harmless Intra-V, its owners, employees, and agents from any claims, damages, liabilities, costs, and expenses, including legal fees, arising out of or related to my use of the red light therapy bed.
I confirm that I have received sufficient information regarding the nature of red light therapy, its potential benefits, and associated risks. I provide my consent to undergo red light therapy under these terms and conditions. I affirm that my participation in red light therapy sessions is entirely voluntary, and I reserve the right to discontinue the treatment at any time. I am under no obligation to continue or complete any specific number of sessions.
Patient Informed Consent for Iron Infusions
I understand that I am voluntarily choosing to receive an Iron Infusion at Revive Room LLC (DBA Intra-V). I acknowledge that I have been informed of the potential risks, benefits, and alternatives to this treatment and have had the opportunity to ask questions before proceeding.
1. Nature of the Procedure
Iron Infusion Therapy involves the intravenous (IV) administration of iron to help replenish iron stores in individuals with iron deficiency or anemia. The iron solution will be delivered directly into my bloodstream over a set period of time.
2. Potential Benefits of Iron Infusions
I understand that Iron Infusions may provide the following benefits:
- Rapid replenishment of iron levels.
- Increased energy, improved focus, and reduced fatigue in those with iron deficiency.
- Avoidance of gastrointestinal side effects associated with oral iron supplements.
- Improved oxygen transport and circulation in the body.
I acknowledge that the results of iron infusion therapy vary from person to person and that no guarantees have been made regarding the effectiveness of the treatment for my specific condition.
3. Potential Risks & Side Effects
I understand that receiving an Iron Infusion may involve certain risks, including but not limited to:
Mild to Moderate Side Effects:
- Temporary flushing, dizziness, headache, or metallic taste during the infusion.
- Nausea, vomiting, or abdominal discomfort.
- Low blood pressure or fainting due to rapid administration.
- Pain, swelling, or irritation at the injection site (phlebitis).
Severe Risks & Reactions (Rare but Possible):
- Anaphylaxis (a severe allergic reaction that may require emergency treatment).
- Breathing difficulties, chest tightness, or throat swelling.
- Severe hypotension (low blood pressure).
- Iron Overload (excess iron accumulation, which can cause long-term complications).
- Hemosiderosis or liver toxicity (in individuals with undiagnosed conditions).
- Severe pain, staining, or burning at the infusion site due to iron leakage into surrounding tissues.
I understand that certain individuals are at higher risk for adverse reactions, including those with a history of allergies to iron infusions, multiple drug sensitivities, or specific medical conditions.
4. Contraindications & Medical History Disclosure
I affirm that I have disclosed my complete medical history and that I:
- DO NOT have a history of severe allergic reactions to IV iron products.
- DO NOT have hemochromatosis (iron overload disorder) or any other condition that may cause excessive iron accumulation.
- DO NOT have active liver disease or severe kidney disease.
- DO NOT have an ongoing infection or inflammatory disorder that may be worsened by iron infusion therapy.
I acknowledge that failure to disclose accurate and complete medical information may increase my risk of adverse effects.
5. Monitoring & Emergency Protocol
I understand that my iron infusion will be administered by trained medical professionals who will monitor me for adverse reactions. In the event of a severe reaction:
- The infusion will be stopped immediately.
- Emergency medications, including antihistamines, steroids, or epinephrine, may be administered if necessary.
- I may be referred for further medical evaluation if complications arise.
6. Alternative Treatment Options
I understand that alternatives to iron infusions include:
- Oral iron supplements (which may cause gastrointestinal side effects).
- Dietary modifications to increase iron intake naturally.
- Blood transfusions in cases of severe anemia.
I acknowledge that I have been given the opportunity to discuss these alternatives with my provider.
7. Financial Responsibility & No Refund Policy
I understand that Iron Infusions are elective treatments and that:
- I am financially responsible for all services received.
- No refunds will be issued for completed treatments, regardless of the outcome.
- I understand that if I experience any side effects or require additional medical attention outside of Intra-V’s services, I am responsible for any additional costs.
8. Voluntary Consent & Acknowledgment
By signing below, I acknowledge that:
- I have read and understand this Iron Infusion Consent & Waiver.
- I have had the opportunity to ask all questions regarding the procedure, risks, and alternatives, and I am satisfied with the information provided.
- I voluntarily consent to receiving Iron Infusion Therapy and assume all associated risks.
- I understand that I may withdraw my consent at any time before or during the procedure.
- I release Revive Room LLC (DBA Intra-V), its providers, nurses, employees, and affiliates from any liability related to the treatment, except in cases of gross negligence or misconduct.