Informed Consent for Intravenous Nutrient Therapy

    ​Informed Consent for Intravenous Nutrient Therapy
    I hereby give consent to Sun Valley Ketamine Clinic to perform intravenous NAD+ therapy.
    • The Procedure involves inserting a needle or catheter into your vein and injecting the solution.
    • Risks of intravenous therapy include
      • ​Discomfort, irritation, bruising and pain at or near the injection site.
      • Inflammation of the vein used for injection (phlebitis)
      • Severe allergic reaction, anaphylaxis, cardiac arrest and death.
    • Benefits of intravenous therapy include:
      • Bypassing the negative effects of gastrointestinal function and absorption.
      • Total bioavailability on the NAD+ solution.
      • Nutrients are forced into cells by means of a high concentration gradient.
      • No intestinal irritation.
    • You have the right to consent or refuse a proposed treatment any time prior. In addition, you may revoke your consent at any time during the treatment at which point the procedure will be terminated.
    I have been informed of possible risks and side effects including but not limited to discomfort at the infection site, thrombophlebitis, fatigue, allergic reaction, congestive heart failure, lowering of blood sugar levels, fever, and chills and generalized complaints. I understand that this therapy should not be used if I am pregnant unless I have severe life threatening disease. I understand the nature of the proposed therapy and the risks and dangers have been explained to me to my full satisfaction. 
    While I understand that there have been no warranties 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 and materials that may be provided to me by the office to educate me about the treatment. I acknowledge that I have had the opportunity to ask questions and with respect to my proposed therapy and the treatments to be utilized and all my questions have been answered to my full satisfaction. My signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of intravenous nutrient therapy in my case and/or any other medical treatments that may be necessary as a result thereof.
All listed prices are the total cost. No hidden charges or fees.
We are centrally located in the Tranquility Wellness Center in Ketchum, Idaho. 630 Sun Valley Rd E, Suite D102, Ketchum, Idaho 83340.
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SVKC is in compliance with all local, state, and federal regulatory organizations including the American Association of Nurse Anesthetists, American Society of Ketamine Physicians, Idaho State Board of Pharmacy, Idaho State Nursing Commission, and the United States Drug Enforcement Administration.
We reserve the right to refuse service based on our clinical impression.​
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