Columbus Functional Medicine Specialist - IV Specialist

Patient Directed INFORMED CONSENT for Ozone, Nutritional IV - IM Therapies

I hereby give my consent to The Whole List Doc to administer Ozone UBI Or Intravenous Therapy Or Sub-Q Or Intramuscular Therapy.

I have been informed and understand that this method involves removing a small volume of my own blood ( from 60 cc to a maximum of 120cc's ) under sterile conditions, briefly exposing that blood to selected frequencies of Ultraviolet Light and re-infusing the blood back into the body. The blood may also be treated with a very small amount of temporary acting anti-coagulant (heparin).

I understand that Ozone UBI Therapy is used clinically as both a specific (ie psoriasis, lymph cancer) and non-specific (chronic infections, chronic fatigue, auto-immune diseases, scleroderma, etc.) immune modulating therapy. Certain forms of auto-immune diseases, infections and tissue transplant rejection have all been published as benefiting from Ozone - UBI 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.

I understand that the nonspecific use of Ozone UBI Therapy is "alternative" and is therefore NOT COVERED BY MEDICARE OR MEDICAID and MAY NOT BE COVERED by private insurance. I understand that BPT therapy is usually administered once or twice weekly for a series ( 4-15 ) of treatments, depending on the condition being treated. I understand that the side effects of Ozone UBI therapy include minor bruising at the injection site, potential minor bleeding from the heparin, mild temporary "healing reactions" (low grade fever, minor muscle aches or joint aches, possible prescription drug - Ozone UBI interaction (ie. sulfa drugs, tetracyclines, phenothiazines) and the rare possibility of photo-allergy in the case of allergy to sunlight. Other side effects although not listed in the literature may also be possible. I have notified the clinical director/staff of ALL PRESCRIPTION MEDICATIONS I am currently taking prior to Ozone UBI therapy being administered. I also understand that in the event of any adverse reaction after the first treatment that I am to contact this clinic for further instructions. If it is an emergency call 911.

I understand that this is a patient directed therapy and I am directing this Clinic to perform the above procedure and that in doing so I, and any and all parties that may represent me or my estate, hold harmless the staff and all other controlling or involved entities or manufacturers. In the event of a dispute, I and/or my above representative parties agree to binding arbitration that follows the rules of the American Arbitration Association.

CANCELLATIONS: We understand that emergencies do arise; however we request at least 24 hour notice for rescheduling or canceling all appointments. Failure to do so may result in your account to be charged. "NO SHOWS’ WILL BE BILLED FOR THE SCHEDULED IV TREATMENT.

APPOINTMENTS: To ensure your preferred RN is always available to you we recommend that you make your next appointment prior to leaving the The Whole List Doc. This is particularly important if you are having a series of treatments over a defined period of time.

ARRIVALS: Please arrive for your appointment in our office on time. This ensures that you will receive the required amount of time you deserve for your treatment and helps us not to intrude on the following patients’ reserved time.

I have READ, UNDERSTAND AND CONSENT to the above.

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