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Lipotropic Injection and B12 Informed Consent
Lipotropic injections aid in weight loss by increasing your metabolism. Vitamin B-12 helps maintain optimal health and has been shown to be beneficial in helping to reduce fatigue, improve memory, and maintain a healthy body weight. It is what your body uses to help create energy, which is one of the reasons people feel more energized when they take B12.
While all components of a lipotropic injection generally have no side effects, you need to remember that all medications and supplements have potential side effects, including B12, methionine, inositol, choline, and amino acids. Most people tolerate B12 and lipotropic injections without issue as side effects are rare.
Potential common B12 side effects include, but are not limited to: mild diarrhea, upset stomach, nausea, pain at the injection site, swelling, headache and joint pain.
Potential common lipotropic injection side effects include, but are not limited to: stomach upset, diarrhea, urinary frequency/urgency/hesitancy, fatigue, elevated heart rate, and restlessness.
You acknowledge:
1. That if I begin to have side effects, I will contact Nissi IV Hydration & Wellness Clinic/ Amanda A. Opoku FNP immediately and notify them of what is happening.
2. I understand that although rare, vitamin B12 injections can result in serious side effects. If these occur, you should follow up with a medical provider or go to the emergency department immediately. Uncommon and dangerous side effects include: rapid heartbeat, chest pain, flushed face, muscle cramps, weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, feeling of tightness in the chest, hives and rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.
3. Before starting vitamin B12 and lipotropic injections I agree to make my Nissi IV Hydration & Wellness Clinic/ Amanda A. Opoku FNP aware if I have any of these conditions: Leber’s Disease, liver disease, kidney disease, iron deficiency, folic acid deficiency, cardiovascular disease, receiving any treatment or taking any medication that has an effect on bone marrow, or drug/supplement allergies.
4. I understand that there could be interactions with B12 and lipotropic injections and certain medications/supplements.
5. The use of B12 and lipotropic injections on a weekly to biweekly basis without a documented B12 deficiency is considered off label use and has not been FDA approved for increasing energy levels and weight loss.
5. Caution is advised while taking B12 if you have a sulfa allergy.
By signing below, I acknowledge that I have read the informed consent and agree to the treatment with its associated risks. I hereby give consent for B12 and/or lipotropic injections. I agree to inform my medical provider immediately if I have any side effects. I hereby release Nissi IV Hydration & Wellness Clinic/ Amanda A. Opoku FNP and the person injecting the B12 and lipotropic injection of any damages or liability if anything was to occur.
IV Infusion and Injection Consent Form
This form outlines that you understand that a peripheral intravenous catheter will be inserted into a vein in your body, and you will have fluids, vitamins, minerals, nutrient, and/or medications infused directly into your body. This is considered “IV Infusion Therapy.” If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.”
Please check off each point below, acknowledging that:
Final patient consent for treatment.
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I have had the nature of the procedure and/or treatment, the benefits of treatment, the risks of treatment, the side effects, the alternative therapies for my medical condition or symptoms I am seeking treatment for, and the chances of treatment success explained to me. I have had all my questions and concerns answered to my satisfaction. I acknowledge that I have been given sufficient information about IV hydration/vitamin/mineral/nutrient infusion and injection therapy and all its associated risks and benefits upon which to make an informed decision about treatment.
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I acknowledge that there are no guarantees regarding the results of treatment and its effect on my presenting condition.
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I give my consent for the use of emergency intervention if required during treatment.
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I certify that I am of sound mind and body to make medical decisions and to consent for treatment.
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I certify I will continue to remain under the care a licensed and qualified primary care provider and/or mental health provider as IV infusion and injection therapy is considered an adjunctive and non-medically necessary treatment option, not a complete one.
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I release Amanda A. Opoku FNP at Nissi IV Hydration & Wellness Clinic and all the medical staff from all liabilities for any complications or damages associated with IV infusion and injection therapy.
I have read this consent and fully understand the information within it and I voluntarily authorize and consent to the treatment options, including but not limited to IV infusion therapy, provided to me at Nissi IV Hydration & Wellness Clinic.
OUR LEGAL RESPONSIBILITIES
We are required by law to give you this notice. It provides you on how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information.
We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information.
You may request a copy of our notice any time. You may contact Nissi IV Hydration & Wellness Clinic, 15 w prospect street East Brunswick NJ 08816 at 732-301-4465 at any time to request a copy of this privacy policy.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed.
Treatment: We may use and disclose your protected health information to provide you treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care.
For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in.
Payment: Your protected health information may also be used to obtain payment from an insurance company or another third part. This may include providing an insurance company your protected health information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you be telephone, email, or text to remind you of your appointments.
If we have to share your protected health information to third party “business associates” such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information.
We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect.
Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email.
Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment if there is an urgent or emergent need.
Research: We will not use or disclose your health information for research purposes unless you give us authorization to do so.
Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation if it is necessary to facilitate this process.
Public Health Risks: We may disclose your protected health information, if necessary, in order to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation.
Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.
Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law.
Workman’s compensation: We may disclose your protected health information to workman’s comp or similar programs.
Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.
Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.
Amendment: If you believe the protected health information, we have about you is incorrect or incomplete, you may ask us to amend the information You will need to submit a written request on why you feel the health information should be amended. We may deny your request to amend if you did not send a written request or give a reason on why it should be amended. If we deny your request, we will provide you a written explanation. We may deny your request if we believe the protected health information is accurate and complete.
Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this “accounting of disclosures” to the individual listed at the bottom of this policy. After your request has been approved, we will provide you the dates of the disclosure, the name of the individual or entity we disclosed the information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information. This information may not be longer than (STATUTE OF LIMITATIONS) years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process.
Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy.
Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you.
Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
Nissi IV Hydration & Wellness Clinic
15 W Prospect Street
East Brunswick NJ, 08816
Please sign and date indicating you have read and understand you’re Patient Rights.
Idemnification Clause
I agree to indemnify, defend, protect, and hold harmless the medical providers employed by Nissi IV Hydration & Wellness Clinic and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Nissi IV Hydration & Wellness Clinic.; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by Nissi IV Hydration & Wellness Clinic. harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Nissi IV Hydration & Wellness Clinic. I am aware of the potential side effects associated with IV infusion and injectable therapies provided by Nissi IV Hydration & Wellness Clinic, accept all the risks involved with IV infusion and injectable therapies, and will not seek indemnification or damages from the indemnified parties.
Nissi IV Hydration & Wellness Clinic
PATIENT CONSENT FOR IV INFUSION AND INJECTION THERAPIES with Nissi IV Hydration & Wellness Clinic.
If you have any questions, please feel free to ask us. Please initial each point acknowledging you understand that:
Informed Consent for Medically Management Weight Loss Therapy
I acknowledge that I am voluntarily entering into a medically managed weight loss program with Nissi IV Hydration & Wellness Clinic. I fully realize that entering any program involving weight reduction, which includes moderate calorie restriction, exercise, and medications, involves potential risks and side effects. The risks include, but may not be limited to the following:
Final patient consent for treatment.
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I have had the nature of the procedure and/or treatment, the benefits of treatment, the risks of treatment, the side effects, the alternative therapies for my medical condition or symptoms I am seeking treatment for, and the chances of treatment success explained to me. I have had all my questions and concerns answered to my satisfaction. I acknowledge that I have been given sufficient information about IV hydration/vitamin/mineral/nutrient infusion and injection therapy and all its associated risks and benefits upon which to make an informed decision about treatment.
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I acknowledge that there are no guarantees regarding the results of treatment and its effect on my presenting condition.
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I give my consent for the use of emergency intervention if required during treatment.
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I certify that I am of sound mind and body to make medical decisions and to consent for treatment.
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I certify I will continue to remain under the care a licensed and qualified primary care provider and/or mental health provider as IV infusion and injection therapy is considered an adjunctive and non-medically necessary treatment option, not a complete one.
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I release Amanda A. Opoku FNP at Nissi IV Hydration & Wellness Clinic and all the medical staff from all liabilities for any complications or damages associated with IV infusion and injection therapy.
I have read this consent and fully understand the information within it and I voluntarily authorize and consent to the treatment options, including but not limited to IV infusion therapy, provided to me at Nissi IV Hydration & Wellness Clinic.