Eileen C. Comia, M.D.
35 Jolley Drive Suite 102
Bloomfield CT 06002
Tel (860)242-2200
Fax (860)242-2212
IVIC 0119
Page 1 of 2
1. I, _________________________________ (DOB: _________), do hereby request and consent to
the use of Intravenous (IV) Nutrient Therapy for the treatment of ______________________. I
understand the procedure will involve intravenous push/infusion possibly combined with diet and
lifestyle modifications.
2. I understand that Intravenous Nutrient Therapy is not currently medically accepted for treating
______________________ and may not be FDA-approved. I am aware and understand the
currently “standard” medically-indicated treatment for my condition.
3. The procedure has some risks. The short and long-term risks may include temporary worsening of
my current symptoms, failure to obtain substantial benefit, bruising/tenderness at IV site,
headache, tachycardia (increased heart rate), syncope (fainting), visual difficulties, shortness of
breath, joint pains, red eyes, itchy eyes, nasal congestion, numbness, gastrointestinal disturbances,
infection, and anaphylaxis. Further side-effects or complications could be:
_______________________________. I accept these risks.
4. Moreover, I understand and accept that because this procedure may be considered “medically
unnecessary” or “experimental”, it may not mitigate, alleviate, or cure condition(s). Its possible
benefits may not be apparent immediately. The possible benefits include improvement of my
current symptoms, improvement of respiratory function, decreased skin reactions, increased
stamina, improved metabolism, improved concentration, and decrease in frequency or severity of
5. I further understand and agree to adhere to the treatment schedule and attend the follow-up visits
set by Advance Biomedical Treatment Center to permit observation and study my progress. I also
agree to comply with the recommended lifestyle modifications in order to provide optimum
opportunities for the beneficial effects of the therapy.
6. I understand that I may terminate my treatment at any time by informing Advance Biomedical
Treatment Center.
7. I assume full liability for any adverse effects that may result from the administration of the
proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have
concerning or resulting from the procedure, except as that claim pertains to negligent
administration of this procedure.
8. I hereby confirm that the nature and purpose of the treatment(s) may be considered medically
unnecessary or experimental and not currently indicated treatments. The risks involved and the
possibilities of complications have been explained to me. I fully understand that the treatment to
be provided may be considered experimental and unproven by scientific testing and peer-reviewed
Eileen C. Comia, M.D.
35 Jolley Drive Suite 102
Bloomfield CT 06002
Tel (860)242-2200
Fax (860)242-2212
IVIC 0119
Page 2 of 2
By signing below, I acknowledge that I have read, understood, and agree with the aforementioned
Patient Name: __________________________________________________
Patient Signature: _______________________________________________ Date: __________
If a minor, both parents must sign and date below. If parents are divorced, please provide proof of
legal child custody.
______________________________________________ _________________
Signature of Father Date
______________________________________________ _________________
Signature of Mother Date