This document is intended to serve as confirmation of informed consent for IV therapy and/or chelation as ordered by Advanced Wellness West Valley Medical Group. I hereby give my willing consent to Advanced Wellness West Valley Medical Group Staff to perform intravenous Calcium EDTA chelation therapy for the purpose of treatment of heavy metal toxicity and/or atherosclerotic disease and/or the prevention or treatment of degenerative diseases. I understand that Chelation Therapy is a standard therapy approved for the treatment of heavy metal toxicity.
I have been made aware that EDTA Chelation is considered controversial for the generalized treatment of atherosclerotic vascular disease, and other degenerative diseases, and the view that it is of benefit in the treatment of such disorders is accepted by a minority of the medical community, and is often considered “experimental” by most physicians and insurance companies. I am advised my treating physician believes that chelation therapy does have positive clinical benefit. I have been informed that other treatment approaches have been used in these conditions, including, but not limited to bypass surgery, or angioplasty and these alternatives have been explained to me to my full satisfaction.
Please Read and Initial All Statements You Have Read:
_______I understand that the benefits of Chelation Therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, proper exercise, proper diet, and nutritional supplementation). I understand that an initial series of treatments are anticipated, and that these treatments may be extended over a number of months. I have been informed that Chelation Therapy may need to be repeated from time to time in the future in order to maintain the benefits. I understand that it is my option to stop this treatment protocol at any time without incurring any further expense after I have decided that such treatment be discontinued.
_______ I have informed the physician of any known allergies to drugs or other substances that may be included in the ingredients of my IV Chelation solutions, or of any past reactions to anesthetics.
_______ I have informed the doctor of all current medications and supplements.
I understand that I have the right to be informed before the procedure of the risks and benefits of the procedure I am choosing to undergo.
The intravenous (IV) procedure involves inserting a needle into your vein and infusing a chelation solution over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids) and/or chelation agents. Chelating agents may be infused for pretreatment testing. Chelation testing helps your physician to develop a chelation treatment plan.
I understand that risks, benefits and alternatives to IVs or IV/Oral chelation may include but are not limited to:
1. The Risks and Potential Side Effects:
2. The Benefits:
3. I understand that there have been no warranties, assurances or guarantees of successful treatment made to me, I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations with my treating physician and through materials provided to me by the office to educate me about the treatment. I acknowledge that I have had the opportunity to ask any questions of my physician with respect to the proposed therapy, and the procedures to be utilized, and all of my questions have been answered to my full satisfaction. I also acknowledge that I have received a copy of this signed, informed consent.
4. Alternatives to intravenous chelation therapy are dietary and lifestyle changes. Alternative therapies to intravenous chelation can improve the natural elimination of metal compounds through appropriate diet. nutritional supplementation and tissue cleansing programs.
I am aware that other unforeseeable complications could occur. I do except the physician(s) to exercise judgement during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in these treatments at any time. I understand that, except in emergencies, I must give 24 hours’ notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials.
My signature below confirms that:
1. I have received all the information and explanation I desire concerning the procedure.
2. I authorize and consent to the performance of the procedure(s)
Patient Name: ______________________________________________
Patient Signature: ______________________________________________
If signed by representative, indicate relationship: ______________________________________________
Patient/Representative Signature: ____________________________________