Intake Acknowledgements

• I hereby give my informed consent to receive an intravenous infusion at Summit Health, having had the opportunity to ask questions regarding the nature, risks, benefits, and alternatives to the proposed treatment. I understand that I may withdraw this consent at any time before or during the procedure.
• I acknowledge and agree to Summit Health’s cancellation policy, which states that cancellations made within 48 hours of the scheduled appointment time, or failure to attend the appointment, may result in a non-refundable charge of $60. I understand that this policy is in place to ensure timely access for other patients.
• If I am supplying my own medication for infusion, I declare that the product has been appropriately stored and transported in accordance with pharmaceutical guidelines, including the maintenance of the cold chain where required. I accept full legal responsibility for the medication’s integrity and release Summit Health from liability related to improper handling or adverse effects caused by the product’s condition.
• If I receive Benadryl (diphenhydramine) or any other sedating medication as part of my treatment, I acknowledge that I have been advised not to drive, operate heavy machinery, or engage in any activity requiring mental alertness for at least 8 hours post-administration. I accept all legal responsibility for any consequences of disregarding this advice.

Discharge Acknowledgement

• I acknowledge that I have elected to leave the clinic prior to the completion of the recommended 60-minute post-infusion monitoring period. I understand the potential risks of doing so and release Summit Health from liability should any delayed reaction or complication occur after my departure.