I, , consent to Ozone therapy of the ears or sinus.

Ozone is not approved by the United States Food and Drug Administration to treat any medical condition including cancer. Ozone is not a cure for any diseases. You should continue ongoing treating physicians. I understand that Ozone is not a treatment for illness or diseases.

I have been informed that while Ozone has shown favorable results in laboratory studies, animal studies, and in some clinical cases for improving outcomes with diseases and illness.

Although I understand this therapy is anticipated to improve my health, I acknowledge my understanding that this therapy is considered controversial and may be deemed an alternative, adjunctive, complementary or unconventional therapy by many conventional physicians in the allopathic medical community because it has not yet been shown to be “safe”, “effective” or “usual, customary, and reasonable”. Further, I have been informed that other treatment approaches have been used in treating these conditions, including, without limitation, conventional drug therapy and surgery and these alternatives have been explained to me to my full satisfaction.

Risks associated with intravenous Ozone include, without limitation, Headache, pain, runny nose, ear pain, dizziness and fatigue.

This list is not meant to be inclusive of all possible risks associated with Ozone treatments as there are both known and unknown side effects associated with any medication or procedure.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.

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 to perform this and all subsequent Ozone treatments with the above understood.

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