CONSENT FOR IMMUNE SUPPORT INTRAVENOUS MEDICATIONS PROGRAMS

I hereby give consent for the administration of Intravenous (IV) medication by either IV Drip or IV Push. The Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs offer the administration of single or combination solutions of vitamin, minerals and other intravenous nutrients given by intravenous (directly into the blood system through a vein) route either by drip (slow administration) or by a single push (rapid administration) methods.

The purpose of the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs is to introduce directly into your body one or more specifically selected vitamins, minerals and nutrients which are either deficient, absent, depleted or being added for specific medical reasons and or to cause specific physical, mental, emotional effects. This occurs in most people because they a poor limited or eat diet or because they already suffer from an illness or medical condition which these nutrients are believed or are known to helpful, will reduce, limit, manage, control physical, mental, emotional signs and symptoms or help to heal this specific illness or illnesses. It is desired, that through the process of rebalancing of the body’s necessary nutrients that the individuals nutritious and/or immune system will reestablish its proper function and protective capacity thereby reestablish wellness and health, treating or curing the problems and causes of these medical conditions.

The Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs generally consist of a series of multiple intravenous injections of a specified combination of vitamins, minerals and other known nutrients necessary to human health and healing. Although these nutrients are commonly and generally part of a balanced healthful diet simply replacing them cannot always guarantee a “cure.” Cure is a function of your own unique-body-mind relationship and will be affected by your desire to be “cured,” your “will to health” and of course, your overall lifestyle, what you continue to eat or give up (alcohol, smoking, a diet which is high in saturated fats.” There is no implied guarantee that either any of our IV or other management or our healing programs will cure you or even help you to feel better. This outcome will ultimately be a function of your original problem, whether your unresolved conflicts or deficiencies are recognized and specifically treated and how well you follow the dietary and other healing suggestions offered by our programs which are designed to help you and your overall health improve. It is possible that more, or even much more than IV fluids, vitamins minerals and specific nutrients used will be necessary for either treatment or cure. This is advanced even though this treatment may well help a lot. You must along with this treatment problem culture your will to live and let it also help you. YOUR RESPONSE TO THESE IV MEDICATION/IV NUTRIENT PROGRAMS WILL ENTIRELY COUNT ON YOU AND YOUR DESIRE TO GET WELL. Our Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs will help you support your overall desire for total wellness and healing.

Although the nutrients used are commonly available their being given through the intravenous drip or push routes of administration presents certain risks which must be understood and agreed to before starting the program. Please read about the risks below and initial each statement you have read, understand and accept:

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1. Inability to administrate (i.e. difficulty finding or getting into a vein or the leaking of the solution out of the vein.)

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2. Redness, soreness, inflammation, discoloration, scaring or degeneration at the site of the intravenous injection or along the vein that has been used. Most often these occupancies are temporary but they can be permanent.
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3. Allergic reaction, anaphylactic reaction, shock even death are possible as they are always possible with the introduction of foreign materials into the body especially through the intravenous route. If you have known allergies to any of the ingredients of Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs please notify the nurse and doctor prior to starting the program.
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4. You may experience certain symptoms of the rapid administration of the Immune Support Intravenous Drip/Push: light headedness, headache, faintness, temporary fatigue, tiredness, flushing, sweating, decreased blood pressure, drop in body temperature, difficulty breathing, diarrhea, itching, swelling locally or generally, peripheral vascular thrombosis (blood clot) at the site of injection or within the vein used.

The Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs should be avoided by any individual if any of the following reasons apply (you should then not sign below). If you sign below to accept either the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip or Push Programs this then means that the following issues are not problems for you:

5.  You do not feel that either of the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs are in your best interest.
6.  You do not wish to get better using either of the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs.
7.  You have known allergy or previous adverse reaction to one or more, or any, of the ingredient nutrients or the combination involved in either of the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs.
8.  You have a known history or history or you or your physicians suspect: kidney impairment, myocardial or heart disease or history of bleeding disorder* .

* If any of these conditions exist please make them known to the doctor and/or the nurse.

Ingredients** of the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs:

• Selenium
• Magnesium Chloride
• Vitamin C Ascorbic Acid
• Copper Sulfate
• Manganese Sulfate
• Lipotrophic M.I.C.
• Aerobic Life – Stabilized Oxygen

** While there is a defined protocol of administration the exact combination and dosages may depend on individual evaluation and needs.

I have read the above Informed Consent for the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs. I fully understand that there are risks and side effects, I have no contraindications or reasons not to be on the program. I am aware that no “cure” is implied or guaranteed. I realize that the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs are only one part of a more comprehensive program to re-establish the integrity and balance of my immune system. I hereby acknowledge all of the above is clear, all my questions have been asked and I have received answers that are satisfactory to me. I acknowledge that my signature acknowledges these as facts. I hereby give my consent for Dr. Allen Lawrence, M.D. and/or Advanced Wellness West Valley Medical Group to perform intravenous injections and treatments as per the Advanced Wellness West Valley Medical Group Immune Support Intravenous Drip and Push Programs Protocols.

Signed:

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Patient Signature                                                    Date

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Witness                                                                     Date