I, hereby request and consent to have the doctors at The Scarlet Drip perform EBOO [Extracorporeal Blood Oxygenation and Ozonation] and BioPhotonic Therapy (BPT, exposure of the blood to both ultraviolet Irradiation [UBI] and full spectrum LED arrays).

I understand that EBOO/BPT therapy is considered experimental medicine and that this therapy is not approved by the Food and Drug Administration (FDA). I understand that no warranty or guarantee has been made as a result of this therapy, and it is not intended to cure any ailment. I have been given the opportunity to have all questions answered about the therapy, how it might apply to my condition, alternatives to this therapy including receiving no treatment, and the probable outcomes.

I have been informed that EBOO/BPT therapy may be of benefit in enhancing immune system function and improving energy levels. In certain instances, however, it may cause a Herxheimer reaction (detoxification reaction) which may cause fever, body aches, and other flu-like symptoms. I understand that the use of the medication Heparin may be used in this therapy. Potential side effects and risks of this medication are:

Easy bleeding, heavy bleeding, prolonged bleeding, and bruising

Pain, redness, warmth, irritation, or skin changes at injection site

Itching of feet

Hair loss

Pain, coldness, or blue color of the skin on the arms or legs

Thrombocytopenia, heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia and thrombosis (HITT) are serious side effects of heparin.

Dizziness or headache

Severe allergic reaction, anaphylaxis, cardiac arrest, and death

I understand that my participation in this treatment is voluntary, and I can withdraw from treatment at any time. This treatment represents a "good faith" effort by The Scarlet Drip. As such, should harm come to me, and since I am freely partaking in this treatment, I will hold harmless the doctors at The Scarlet Drip and The Scarlet Drip of this treatment. I also understand that I am likewise biding my representatives, estates, successors, and assigns to hold harmless, the doctors at The Scarlet Drip and The Scarlet Drip of this treatment. I understand that insurance companies have determined this therapy to be experimental, and insurance companies will not pay for this therapy.

I do not expect the doctors at The Scarlet Drip to be able to anticipate and explain all the risks and complications of this therapy and understand that other unforeseeable complications could occur. The possible risks of this treatment may include, but are not limited to:

Abdominal cramps

Burning eyes

Cough

Headache

Dizziness, nausea, and/or fainting during and/or after treatment

Herxheimer reaction (detoxification reaction) during which you feel flu-like symptoms

Possible contraindications of EBOO/BPT may include, but are not limited to:

Alcohol intoxication

Recent heart attack

Recent stroke

Pregnancy

Active seizures

Seizure disorder

Use of blood-thinning medications (anti-coagulants, aspirin, other)

Hypoglycemia (low blood sugar)

Untreated hyperthyroidism (elevated thyroid hormone levels)

Ozone allergy and/or intolerance

G6PD deficiency due to possible hemolysis (red blood cell rupture)

Thrombocytopenia (low platelets)

Internal bleeding

I understand that an absolute contraindication to this treatment is: ALLERGY TO HEPARIN.

I understand that an absolute contraindication to this treatment is: ACTIVE BLEEDING.

I understand that an absolute contraindication to this treatment is: ASPIRIN THERAPY IN DOSAGES GREATER THAN 326mg PER DAY.

I understand that I must come to the clinic for my EBOO treatment having eaten a meal within the 90-120 minutes prior to my treatment.

I certify that I have had the opportunity to thoroughly discuss the possible risks, complications, and contraindications of EBOO/BPT.

Final Consent

I attest that I have no known allergy to the medication, HEPARIN:

I attest that I am not actively bleeding in any part of my body that I am aware, nor have I been told that I have active bleeding in my body:

I hereby acknowledge that I take full responsibility for the administration of EBOO/BPT:

I understand that BPT is used clinically as both a specific and non-specific immune-modulating therapy. Certain forms of auto-immune diseases, infections, and tissue transplant rejection have all been published as benefiting from EBOO/BPT therapy. Although there are many positive medical studies and testimonies, I realize that this alternative treatment is not guaranteed to cure or improve my condition; this is not a standard of care procedure.

If for any reason The Scarlet Drip is unable to complete this treatment (for instance and the most probable would be poor venous access), a nominal supply charge of $175.00 will apply:

I understand that the nonspecific use of EBOO/BPT is an "alternative" and not approved by the FDA and is therefore NOT COVERED BY MEDICARE OR MEDICAID and NOT COVERED by private insurance:

I understand the potential side effects of EBOO/BPT therapy, including minor bruising at the injection site, minor bleeding from the heparin, mild temporary "healing reactions" (low-grade fever, minor muscle aches), and possible prescription drug interactions:

I am responsible for being aware of all prescription medications I am currently taking, and I have communicated this to the physician:

I understand that this is my decision to undergo EBOO/BPT and that in doing so I, and any and all parties that may represent me or my estate, hold the staff and physicians at The Scarlet Drip harmless and agree to binding arbitration in case of dispute.

I understand that this is my decision to undergo EBOO/BPT and that in doing so I, and any and all parties that may represent me or my estate, hold the staff and physicians at The Scarlet Drip harmless and agree to binding arbitration in case of dispute:

Signature:

Date:

Submit Consent