Book an AppointmentBook Now
Consent Form - NAD+ Therapy

NAD+ IV consent form

What is NAD?

  • Nicontinamide Adenine Dinucleotide is a coenzyme central to metabolism.
  • It is found in all living cells and consists of two nucleotides joined through their phosphate groups.
  • NAD acts as a coenzyme for redox reactions, making it central to energy metabolism.

What is NAD used for?

  • Improves cognitive function, energy, weight management, reduces pain, can reduce and reverse some aging and more.
  • It does this as a key function of our cells in the mitochondria that converts food to energy and maintains the integrity of our DNA.
  • NAD aids in the production of ATP.
  • It has a plethora of benefits, from improving athletic performance, reducing fatigue, high cholesterol, mood, blood pressure, slowly reduces aging, neurodegenerative diseases and reversing alcohol effects on the liver.
  • oIt's mechanism of action as a coenzyme is part of the oxidoreductases in our body, which gives it the broad range of effects

Have any of your medications or chronic medical conditions changed since your last IV? NO / YES (If yes, please explain in detail and talk to your medical provider prior to treatment)

  1. You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent.
    • This is an elective procedure.
    • This procedure involves inserting a needle into your vein and injecting the formula ordered by your medical provider.
    • Alternatives to intravenous therapy are doing nothing, taking oral supplementation and/or dietary and lifestyle changes.

Risks of intravenous therapy (nutritional, high dose Vit C, NAD, etc), although very rare, may include:

  • Discomfort, bruising, bleeding and pain at the site of injection.
  • Nausea, shakes, chills, tremors, headache, chest pain or tightness, tingling in extremities, lightheadedness.
  • Inflammation of the vein used for injection (phlebitis)
  • Infection at the site of injection or systemic in the body.
  • Fluid, sodium, iron or other nutrient overload.
  • Shortness of breath
  • Blood sugar fluctuations and falsely elevated blood glucose readings.
  • Hemolysis with G6PD deficiency.
  • Kidney stones.
  • Exhaustion or fatigue.
  • Detox side effects - such as flu like symptoms.
  • Severe allergic reaction, anaphylaxis, cardiac arrest and death.
  1. You have the right to consent to or refuse the proposed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent to the procedure(s) described above with any different or further procedures which, in the opinion of your medical provider, may be indicated.
  2. The procedure will be performed by or under the direction of a licensed physician or nurse practitioner or a physician assistant.

Your signature below means that:

  1. You understand the information provided on this form and agree to the foregoing.
  2. Females only- You assure and confirm that you are NOT Pregnant, or possible to be pregnant, or and you are NOT currently breast feeding.
  3. You assure and confirm that you do NOT have any form of cancer, or a history of cancer and you have disclosed if you have any first degree relatives with cancer associated with a genetic link.
  4. You assure and confirm that you do NOT have severe cardiovascular disease or uncontrolled hypertension.
  5. You agree that no refunds will be provided after you agree to receive the procedure regardless of if you elect during the procedure to stop the service.
  6. The procedure(s) set forth above has been adequately explained to you by your medical provider. (MD, FNP or and PA)
  7. You have received all the information and explanation you desire concerning the procedure.
  8. You authorize and consent to the performance of the procedure(s).

BY SIGNING BELOW, YOU ACKNOWLEDGE HAVING BEEN INFORMED TO YOUR SATISFACTION ON THE PROPOSED THERAPIES. YOU VOLUNTARILY ELECT TO UNDERGO THEM, AND YOU AUTHORIZE THEIR PERFORMANCE.YOU ASSUME THE RISK ASSOCIATED WITH USING THIS TREATMENT.YOU FURTHER RELEASE AND AGREE TO INDEMNIFY, HOLD HARMLESS AND RELEASE ANY LIABILITY TO ANY OF ZMED  CLINIC’S LOCATIONS AND ANY OF ITS DIRECTORS, OFFICERS, PROVIDERS, DOCTORS, PARENTS, SUBSIDIARIES, EMPLOYEES, AGENTS, OR VOLUNTEERS FOR LIABILITY FROM ANY BODILY INJURY, PROPERTY DAMAGE, OR OTHER LOSS INCURRED FROM PERFORMANCE OF THE THERAPIES, EVEN THOUGH CAUSED IN WHOLE OR IN PART BY A PRE-EXISTING DEFECT, THE NEGLIGENCE (WHETHER SOLE, JOINT, OR CONCURRENT), GROSS NEGLIGENCE, STRICT LIABILITY, OR OTHER LEGAL FAULT OF THE CLINIC OR ITS ACTORS.

Sign here
Skip to content