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Patient Directed INFORMED CONSENT for IV - IM Therapy

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I hereby give my consent to The Whole List Doc to administer Ozone UBI, Intravenous, and/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 photoallergy 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 ofALL 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. I have READ, UNDERSTAND AND CONSENT to the above. *

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Patient Directed INFORMED CONSENT for IV - IM Therapy

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