Informed Consent for Hi-Dose Major Autohemotherapy with UBI IV Treatment

Patient Information

Patient Name:

Today's Date:

Date of Birth:

Email:

Phone:

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Introduction

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Required Attestations

I have read and understood the provided information.

I have had the opportunity to ask questions and received satisfactory answers.

I understand the potential benefits, risks, and alternatives.

I voluntarily consent to undergo Major Autohemotherapy IV treatment.

I understand I may withdraw my consent at any time without penalty.

I understand this is NOT an FDA approved therapy.

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Contraindications

Select any that apply (leave blank if none):

Currently taking antibioticsCurrently taking light-sensitizing medicationsG6PD deficiencyAllergy to heparin or anticoagulantsSensitivity to ozoneSevere cardiovascular diseaseHyperthyroidismBleeding disordersRecent heart attackRecent strokeSevere anemiaAcute alcohol intoxicationPregnancyBreastfeeding

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Patient Responsibilities

I will inform my provider of all medications, supplements, and treatments, follow pre/post instructions, and report any adverse reactions.

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Confidentiality

I understand my medical records and treatment details will be kept confidential unless I provide written consent.

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Signatures

Patient Signature (type full name):

Date:

Print Name:

Provider Signature: "Scarlet Drip"