Injectable Treatment Consent Form

Fields marked with an * are required

That she/he recommends I receive intravenous and/or intramuscular Supplement injections. Treatments recommended may include PRP, Botox, Fillers, Glucose or Vitamin injections, epidurals, nerve blocks, excisions of tissues, intravenous infusions and intramuscular injections.

I understand:

  • That injections may be outside the parameters of conventional medicine in Australia.
  • That this treatment is supported by empirical knowledge and by research data
  • That this treatment is safe, widely and successfully used by Integrative Medical practitioners in centres in Australia and overseas, and is only prescribed and administered with utmost care.
  • That this treatment is not covered by Medicare and may not be covered by private health insurance funds.
  • That this treatment may not be regulated by the Therapeutic Goods Administration (TGA) and that Dr David Jaa deems that this treatment is in my best interest.  Also that Dr David Jaa has made me fully aware of any risks associated with this treatment and has provided me with sufficient information to make an informed decision.

Possible Side Effects

  • Local anaesthetic complications:  nerve damage, nausea, vomiting, disorientation, fitting, loss of blood pressure, high blood pressure, coma, death.
  • At times you will not be able to drive home post procedure
  • Intramuscular iron injections may cause permanent brown discolouration of the skin
  • Extreme allergy from any substance or object penetrating the skin, resulting in itch, hives, asthma, and even death.
  • Possible side effects from intravenous infusions may include:
    • Haemolysis for patients with GCPD deficiency if high dosage given
    • Headaches
    • Nausea
    • Vomiting
    • Trembling
    • Fatigue
    • Mild Dehydration
    • Local irritation of veins (eliminated by flushing at end of IV)
    • Chest pain
    • Shortness of breath or other breathing issues
    • Tightness in the throat and chest
    • Allergic reaction-type symptoms (breaking out into hives, rashes, swelling up, or excessive itchiness)
    • Magnesium caution in patients with kidney problems
    • Heart block
    • Low blood pressure
    • Confusion
    • Upset stomach
    • Hypotension
    • Diarrhoea
    • Increased Amylase
    • Pregnancy lactation (ALA0
    • Interaction with Metformin
    • Skin irritation
    • Hypoglycaemia

I am agreeing to this treatment of my own free will and consent and exercise my right to discuss and choose any treatment(s) made available to me.

I also understand the results are variable between different individuals.

CONSENT:

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