Consent for Activated Oxygen TherapyActivated Oxygen Therapy ConsentDate* MM slash DD slash YYYY Name* First Last Consent to TreatmentI am choosing, of my own free will, to receive intravenous activated oxygen therapy. These alternative therapies (Hydrogen Peroxide, Ozone, Ultraviolet Blood Irradiation), although discounted by conventional medicine, have a 50 year track record of safety. Kirk Wlson, RN, BSN, CEN is certified in Ozone Therapy by the American Academy of Ozonotherapy, and he or a trained RN under his direction will be administering my treatment under the orders of Dr. Ken Ota, DO.I affirm that I do not currently present any of the following conditions: Allergy to Heparin, Pregnancy, Anemia, Thyrotoxicosis, Hemophilia, Porphyria, Acute Disc Herniation, Extremely Low Platelet Count, Atopic Dermatitis, Photo-Sensitivity, or Photo-Active Medication.I affirm that I do not currently present any of the following conditions: Allergy to Heparin, Pregnancy, Anemia, Thyrotoxicosis, Hemophilia, Porphyria, Acute Disc Herniation, Extremely Low Platelet Count, Atopic Dermatitis, Photo-Sensitivity, or Photo-Active Medication. AgreeI understand that as with any intravenous therapy, risks include: bleeding; transient hypoglycemic headache and/or light-headedness; local swelling, bruising, irritation or infection at the insertion site; a brief resetting of my menstrual cycle; slight hemolysis if I have a G6PD deficiency.I understand that as with any intravenous therapy, risks include: bleeding; transient hypoglycemic headache and/or light-headedness; local swelling, bruising, irritation or infection at the insertion site; a brief resetting of my menstrual cycle; slight hemolysis if I have a G6PD deficiency. I AgreeI understand Prana Wellness Institute LLC (DBA Prana IV Therapy), Kirk Wilson, RN, and Dr. Ken Ota, DO make no warranties, claims or guarantees about these alternative therapies with respect to my condition. I am freely partaking in this treatment, and as such my willing participation in this treatment represents a “good faith” effort by the provider and physician. Should harm come to me, I and my representatives will hold harmless Prana Wellness Institute, LLC and Dr. Ken Ota, DO.I understand Prana Wellness Institute LLC (DBA Prana IV Therapy), Kirk Wilson, RN, and Dr. Ken Ota, DO make no warranties, claims or guarantees about these alternative therapies with respect to my condition. I am freely partaking in this treatment, and as such my willing participation in this treatment represents a “good faith” effort by the provider and physician. Should harm come to me, I and my representatives will hold harmless Prana Wellness Institute, LLC and Dr. Ken Ota, DO. I AgreeI acknowledge that it is my right to cease activated oxygen therapy at any time.I acknowledge that it is my right to cease activated oxygen therapy at any time. I AgreeI understand that I should follow up with my primary care physician within 3 days if I should have any symptoms.I understand that I should follow up with my primary care physician within 3 days if I should have any symptoms. I AgreeI am consulting with Prana IV Therapy solely for reasons concerning my own health. I am not consulting with Prana IV Therapy to provide information to any enforcement or investigative agency.I am consulting with Prana IV Therapy solely for reasons concerning my own health. I am not consulting with Prana IV Therapy to provide information to any enforcement or investigative agency. I AgreeI understand that this procedure is not covered by insurance carriers.I understand that this procedure is not covered by insurance carriers. I AgreeWith full awareness of the above facts and considerations, I give my consent to Prana IV Therapy to receive one or multiple of these activated oxygen therapies.Signature*I acknowledge that my treating doctor has the appropriate expertise and experience to order this infusion, and that despite all due professional care and responsibility, it is possible that the anticipated result may not be achieved, and complications may occur. I have had the opportunity to ask questions about the above procedure and I am satisfied that I understand the information I have received. I hereby consent to these infusions and accept all risks and wish to proceed with treatment.
