Z Medi Clinics and Z Medi Spa

Consent for undergoing activated oxygen therapies (Ozone) With ultravilet blood irradiation (UBI)

I understand that the licensed healthcare provider (MD, DO, PA or NPs) at ZMedi Clinic Providers PA is recommending one or multiple intra-venous activated oxygen (Ozone) therapies with Ultraviolet Light (UVBI) for me. This therapy, although not used typically in conventional medicine and unapproved by any healthcare insurance have a track record of safety and efficacy, However, the safety and efficacy of this therapy is NOT recognized or approved by the Food and Drug Administration (FDA).

I understand that these treatments are intended to enhance cellular oxygen utilization, blood flow, cellular healing and pain relief. By way of protein-like molecules called cytokines, these therapies are intended to stimulate immune system activity. I understand that depending on the type and dose of activated oxygen therapy I receive, some effects may be more anti-inflammatory and anti-microbial, whereas others may promote cellular regeneration and immune modulation. All these therapies, to the extent that they enhance tissue oxygenation and blood flow, are intended to relieve pain and inflammation, up-regulate antioxidant enzyme defenses. I understand this research has been documented in peer reviewed medical and scientific journals and that the therapy(ies) advocated, are not considered dangerous, when administered within the limits and standards of a trained medical practitioner.

I understand that should I currently be in any of the following conditions, one or more of these therapies may not be appropriated for me: Pregnancy, Thyrotoxicosis, Hemophilia, Porphyria, and extremely low platelet count.

Also, I understand that as with any intravenous therapy, I might experience:

• transient hypoglycemic (low blood sugar)
• headache and/or light-headedness
• local swelling, Inflammation of the vein used for injection, Severe allergic reaction, anaphylaxis
• slight hemolysis if I have a G6PD deficiency.

Major Autohemotherapy (MAH) requires that up to 250ml of blood be drawn, which is about half of the volume typically withdrawn during blood donation process. For this reason, possible side effects will be like that which occurs from blood donation, including lightheadedness, nausea, or fainting.

Risks of having blood drawn include temporary pain from a needle stick, bruising and rarely infection. During Major Autohemotherapy, the blood is diluted with saline and heparin is added to prevent clotting and allows us to reinfuse the blood once it has been infused with the Ozone. Allergic reactions to heparin are rare, but possible.

Side effects may occur from introduction of ozone into the body including but not limited to:

• Shortness of breath
• Blood vessel swelling
• Poor circulation
• Heart problems
• Stroke and even death

Alternatives to this therapy have been discussed with me and include:

• IV therapies, without ozone.

I understand at Z Med Clinic /or any representative of Z MED CLINICs make no warranties or guarantees about these therapies with respect to my condition. I do, however, understand the broad application of these therapies to sub-optimal oxygenation states, which is the underlying abnormality in many chronic conditions. I further acknowledge that it is my right to cease activated oxygenation therapy at any time.

Patient Payment Agreement:

I agree to pay $50 deposit to cover some of the cost of supplies, medication and/or supplements in advance, before starting my treatment

Finally, I understand that my insurance carrier will likely NOT pay for OZONE therapies. With full awareness of the above facts and considerations,

I give my consent to Z Med Clinic and/or anyone representing Z Med Clinic at any of its locations for giving me one or multiple treatments of activated oxygen therapies including Major