IV VITAMIN THERAPY CLINIC PATIENT INTAKE FORM
Medical History(Please check if you have had or have any of the following)
IV Vitamin Therapy Clinic Consent to Treatment
Intravenous (IV) therapy as used in this office is a means to deliver nutrient substances, and other medications, to your body while avoiding the digestive process. This is helpful in many cases where patients are depleted of certain nutrients, or when the substance can have more medicinal value through the IV route.
Most patients have no adverse effects on the type of IV therapy we offer.
Some common effects that may come and go but are generally safe MAY be:
• A warm/tired or relaxed feeling from the minerals in the IV
• Slight to moderate lightheadedness
• Short term blood sugar changes
• Discomfort at the IV site during or after the treatment
These effects are best dealt with as they arise, and we will give you specific instructions to help avoid or shorten them. It is your responsibility to inform us immediately if you feel any discomfort or sensation that is unusual.
Infiltration of the IV (the fluid leaking out of the vein and into the surrounding tissues) is an occasional occurrence in all IV therapy. It can cause pain, swelling, and bruising on occasion. This is rare in our office practice as the IV time is relatively short (as compared with IV duration in the hospital setting). If this occurs we will treat it as necessary. The effects of infiltration can be uncomfortable but do go away. If you notice pain, swelling or bruising around your IV site please let us know. Immediately apply ice as well.
Similarly to infiltration, the vein may become sore or slightly swollen or warm after an IV. This is typically irritating but not dangerous, and the vein may feel firm for one to five weeks.
Notify us of this immediately as well.
Although materials injected in this clinic are generally safe and well-tolerated by the body it is important for you to understand that all injections may cause very rare but potentially serious or even life-threatening reactions. We will and do take necessary precautions to avoid serious complications – but you need to know that they exist, however rare the risk may be.
I HAVE READ, UNDERSTAND, AND HAD ALL MY QUESTIONS ANSWERED ABOUT THIS PROCEDURE AND ITS RISKS AND BENEFITS TO ME.
I.V Vitamin Therapy Clinic
High Dose Vitamin C - Ascorbic Acid Description
The chemical name of Ascorbic Acid is L-ascorbic acid. The molecular formula is C6H806. Ascorbic Acid is also known as vitamin C. Ascorbic acid for intravenous use is preservative-free hypertonic, sterile, nonpyrogenic solution. Ascorbic acid must be diluted with an appropriate infusion solution (e.g. 5% Dextrose Injection, USP, Sterile Water for Injection, USP) Each mL of undiluted vial of Ascorbic acid solution contains 500 mg of Ascorbic Acid and 0.3 mg of edetate disodium. Sodium hydroxide has been used for pH adjustment (pH range 5.5 to 7). Undiluted vial of Ascorbic Acid injectable solution has the osmolarity of is approximately 5,95 mOsmol/ml It contains no bacteriostatic or preservatives. Please read all of this leaflet carefully before you start using this medicine because it contains important information for you. Keep this leaflet. You may need to read it again. If you have any further questions, ask your doctor or nurse. This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
1. What Ascorbic Acid is and what it is used for:
Ascorbic Acid is a water-soluble vitamin that takes part in many vital processes in the body. Ascorbic acid is recommended for the prevention and treatment of scurvy. Its parenteral administration is desirable for patients with an acute deficiency or for those whose absorption of orally ingested Ascorbic Acid is uncertain. Symptoms of mild deficiency may include faulty bone and tooth development, gingivitis, bleeding gums, and loosened teeth.
2. What you need to know before you use Ascorbic Acid
Warning and Precaution
Talk to your Practitioner:
• If you are allergic to ascorbic acid or any of the other ingredients of this medicine (listed in the description).
• If you have hyperoxaluria (increased amount of oxalates in urine).
• If you have oxalate urolithiasis (type of kidney stones). Acidification of urine by large doses of ascorbic acid might cause precipitation of urate, oxalate or cystine stones or drugs in the urinary tract, especially since some ascorbate is metabolized to oxalate.
• If you suffer from glucose-6-phosphatdehydrogenase deficiency (lack of an enzyme in the red blood cells);
• If you suffer from kidney disease, including kidney stones; If you suffer from hemochromatosis (impaired iron metabolism), blood diseases - thalassemia, sickle cell anemia (a condition in which the oxygen-carrying pigment, called hemoglobin, in the blood is abnormal), sideroblastic anemia (type of anemia caused by disorder of iron metabolism in the body).
• If you are pregnant.
Tell your Practitioner or nurse if you are taking any of the following medicines:
• Limited case reports have suggested interference of ascorbic acid with the anticoagulation effects of warfarin, however, patients on warfarin therapy, treated with ascorbic acid doses up to 1000 mg/day for 2 weeks (twice the maximum recommended duration), but no effect was observed. However, standard monitoring for anti-coagulation therapy should continue during ascorbic acid treatment, as per standard
• Iron-containing medicines, because Ascorbic Acid can increase the iron absorption in the digestive tract.
• Isoprenaline (a medicine used in the treatment of heart block and cardiac arrest), because concomitant administration with Ascorbic acid decreases the effect of isoprenaline.
• Disulfiram (in support to treat alcoholism), because chronic use or high doses of Ascorbic Acid may interfere with the disulfiram - alcohol interaction.
• Mexiletine (for treatment of irregular heartbeat), because the use of large doses of Ascorbic Acid may accelerate the urinary excretion of mexiletine.
• Fluphenazine, other phenothiazine derivatives (for treatment of schizophrenia), because concomitant administration with Ascorbic Acid leads to a reduction of their therapeutic effect.
• Amphetamines (central nervous system (CNS) stimulants) and tricyclic anti-depressants (for the treatment of depression), because Ascorbic Acid decreases renal tubule reabsorption of amphetamines and tricyclic anti-depressants, and lowers serum concentrations of amphetamines. In case of decreased amphetamine efficacy discontinue Ascorbic Acid administration. Standard monitoring of therapy is warranted.
• Aluminum containing medicinal products: because Ascorbic Acid may enhance the absorption of alum and potentiate undesirable effects.
• Alcohol, because alcohol reduces Ascorbic Acid level.
• Ascorbic Acid may decrease activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin. Bleomycin is inactivated in vitro by ascorbic acid. If the antibiotic efficacy is suspected to be decreasing concomitant administration of Ascorbic Acid, discontinue administration.
Laboratory tests and Vitamin C:
• Ascorbic Acid as a redox-compound affects various oxidative-reduction tests for the determination of glucose in the urine, therefore serum administration of Ascorbic Acid should be discontinued 1-2 days before such a test. Diabetic patients taking more than 500 mg of Ascorbic Acid daily may obtain false readings of their urinary glucose test.
• Ascorbic Acid at high doses can compromise the test results of transaminases, lactate dehydrogenase, and bilirubin.
• No exogenous Ascorbic Acid should be ingested for 48 to 72 hours before amine dependent stool occult blood tests are conducted because possible false-negative results may occur. Use of Ascorbic Acid (greater than 1 g daily) may cause a false-negative guaiac fecal occult blood test. Ascorbic Acid should be discontinued if interference with a guaiac test is suspected.
• Ascorbic acid has been reported to interfere with screening tests for acetaminophen in urine, causing negative screening tests to occur in the presence of acetaminophen. Large doses of Ascorbic Acid (i.e., greater than 500 mg daily) may interfere in carbamazepine levels when measured by the Ames ARIS(R) method.
Animal reproduction studies have not been conducted with Ascorbic Acid Injection. It is also not known whether Ascorbic Acid Injection can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Ascorbic Acid Injection should be given to a pregnant woman only if clearly needed. There are no available data on the use of Ascorbic Acid injection in pregnant women.
There are no data on the presence of Ascorbic Acid in human milk following intravenous dosing in lactating women. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Ascorbic Acid and any potential adverse effects on the breastfed child from Ascorbic Acid or from the underlying maternal condition.
Use in Pediatric patients
The safety profile of ascorbic acid in pediatric patients is similar to adults; however, pediatric patients less than 2 years of age may be at higher risk of oxalate nephropathy following Ascorbic Acid administration due to age-related decreased glomerular filtration. Ascorbic Acid is administered in adolescents under 18 years. children, infants, and neonates. Dose and the therapy duration of treatment are determined by your doctor.
Use in Geriatric Patients
The glomerular filtration rate is known to decrease with age and as such may increase the risk for oxalate nephropathy following Ascorbic Acid administration in the elderly population.
Ascorbic Acid should be used with caution in scorbutic patients with a history of or risk of developing renal oxalate stones or evidence of renal impairment or other issues (e.g., patients on dialysis, patients with diabetic nephropathy, and renal transplant recipients). These patients may be at increased risk of developing acute or chronic oxalate nephropathy following high dose Ascorbic Acid administration.
3. Possible side effects and adverse reaction
Ascorbic acid is generally nontoxic. The most common adverse reactions are pain and swelling at the site of infusion. Other adverse reactions that have been reported are flushing headache, nausea/vomiting, and abdominal cramps, and diarrhea. Very high doses of Ascorbic Acid can cause allergic reactions. In massive ascorbic acid overdose renal failure may occur. If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.
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