IM Injections Consent Form

Informed Consent for Intramuscular Injections

This document is intended to serve as confirmation of informed consent for IM injections as ordered by Michele Lane, DNP, APRN, CNP-F, L3 Aesthetics

I understand that I have the right to be informed during the procedure, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. The IM procedure involves inserting a needle into your muscle and administering over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids). I understand that risks, benefits and alternatives to IMs or may include but are not limited to: 1. The Risks and potential side effects Discomfort, bruising, redness, and pain at the site of injection. Severe reaction, anaphylaxis, cardiac arrest, or death. 2. The Benefits Injectables are not affected by stomach or intestinal disease. Higher doses of nutrients can be given in the muscle than by mouth without intestinal irritation that can accompany doses given by mouth. 3. Alternatives to intramuscular vitamin therapy are oral supplementation and/or dietary and lifestyle changes. I am aware that other unforeseeable complications could occur. I do not except the provider(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 IM injections with any different or further procedure, which in the opinion of my provider(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 procedure(s) set forth above has been adequately explained to me by my provider(s) or other(s) associated with this practice. I understand that I am free to withdraw my consent and to discontinue participation in their 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)
I have informed the doctor of all current medications and supplements.(Required)
I have informed the physician of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics.(Required)