Medical Questionnaire

Infusion consent

Please read carefully. You must agree to the statements below before your infusion can be booked.

1. Nature of the treatment

I understand that this appointment is for an intravenous (IV) infusion, in which a needle or catheter is placed into a vein and medication or fluid is administered. I have had the opportunity to ask questions about the purpose, benefits, risks and alternatives to this treatment — including the alternative of having no treatment — and to have those questions answered. I understand I may ask further questions of the nurse or physician at any time before or during the infusion.

2. Risks I understand and accept

No medical procedure is without risk. I understand that even when an infusion is carried out correctly, complications can occur. These include, but are not limited to:

• pain, bruising, bleeding, swelling or inflammation at the IV site;
• leakage of the medication into the surrounding tissue (infiltration or extravasation), which can cause tissue damage and, with certain medications such as iron, permanent staining of the skin;
• infection at the IV site;
• dizziness, nausea, or fainting;
• an allergic reaction, ranging from a mild rash or itching to a severe and life-threatening reaction (anaphylaxis);
• reactions specific to the medication being infused, which the nurse or physician will review with me;
• rarely, serious complications requiring emergency care or admission to hospital, or resulting in permanent injury or death.

I understand that Summit Health cannot guarantee any particular result or outcome from this treatment.

3. Monitoring and emergency care

I agree to remain at the clinic for the monitoring period recommended by my nurse — normally 60 minutes — after my infusion, so that a delayed reaction can be identified and treated. I authorize the clinic's staff to provide emergency treatment, including medications such as epinephrine, and to call emergency services, if in their professional judgment this is necessary. If I choose to leave before the end of the monitoring period, I understand I am doing so against advice and accept the risks of doing so.

4. Sedating medication

If I receive Benadryl (diphenhydramine) or any other sedating medication as part of my treatment, I understand that I must not drive, operate machinery, or do anything else requiring mental alertness for at least 8 hours afterward, and that I am responsible for arranging alternative transportation.

5. Medication that I supply myself

If I supply my own medication for the infusion, I confirm that it was obtained through a legitimate pharmacy, that it is unexpired, and that it has been stored and transported as the manufacturer requires, including keeping it refrigerated where that is required. I accept responsibility for the condition and integrity of that medication. Summit Health is not responsible for the quality, potency or safety of medication that I provide, or for harm resulting from its improper storage, handling or transport before it reaches the clinic. I understand that clinic staff may refuse to administer any medication they judge to be unsafe or improperly stored, and that the cancellation policy below still applies if that happens.

6. Accuracy of the information I have given

I declare that the health information in this questionnaire is complete and accurate to the best of my knowledge, including allergies, current medications, and medical conditions. I understand that clinical decisions will be made in reliance on this information, and that if it is incomplete or inaccurate health could be put at risk.

7. Cancellation and lateness

I understand that a charge of $60 applies if I cancel within 48 hours of my appointment or do not attend, and that if I arrive more than 15 minutes late my appointment may not be honoured and the same charge may apply.

8. My right to withdraw

I understand that my consent is voluntary, and that I may withdraw it at any time before or during the infusion without affecting my future care at Summit Health.