OZONE THERAPY CONSENT FORM
About Ozone Therapy
Ozone is a gaseous molecule made of pure oxygen that is thought to stimulate the body's natural healing processes. Ozone therapy is felt to have health-promoting effects, including modulating immune function, improving energy, reducing pain and weakness, and supporting the immune system against chronic and acute infection and the effects of aging.
Kōena Integrative Medicine offers ozone therapy as a wellness-oriented service. We do not claim that ozone therapy treats, cures, or prevents any disease. It is not considered medically necessary, and it is recommended for its general health-promoting benefits, intended to support and improve your overall condition — not as a replacement for treatment of a diagnosed medical condition.
The therapy you will receive today uses major autohemotherapy: a small amount of your blood is drawn, mixed with a medical-grade oxygen/ozone mixture, and returned to your body. Other modes of administration your provider may recommend involve inserting an intravenous catheter and delivering fluid into a vein, muscle, or joint.
Risks
As with any procedure, there is always some risk, however rare. Allergic reactions are possible with almost any treatment and, in a worst-case scenario, could be serious. Some patients experience a Herxheimer reaction — flu-like symptoms (fever, chills, aching, headache, fatigue, rash) caused by the die-off of infectious organisms, which are generally self-limiting and mild to moderate.
Risks specifically associated with intravenous administration, though rare, include:
Burning or stinging at the infusion site
Muscular spasms, weakness, or fatigue
Local thrombophlebitis (vein inflammation)
IV infiltration into surrounding tissue, causing temporary burning or stinging
No allergy-related responses have been knowingly reported with this therapy to date.
Notice to Cancer Patients
Kōena does not treat cancer. We support the immune system so that it can respond more effectively. Healing occurs through restoring the immune system to full function — when a patient's own immune system is strong enough, it is able to address the cancer itself.
Your Responsibility
It is your responsibility to keep your Kōena provider up to date on all current medications and supplements you are taking, so they can make the best-informed recommendations for your care.
Notice of Privacy Practices
Your health information may be used by Kōena staff, or disclosed to other healthcare professionals, for the purpose of reviewing your health and providing your care. Results of labs and procedures will be available in your medical record to health professionals and staff involved in your treatment. We will use your contact information to send appointment reminders. You have the right to request a printed copy of our full Notice of Privacy Practices.
Informed Consent
I do not expect my nurse and/or doctor to be able to anticipate and explain every possible risk or complication, and I am willing to rely on their judgment in recommending treatment that they believe, based on the facts known to them at the time, is in my best interest. I have had the opportunity to ask questions and discuss the following with Kōena's clinicians to my satisfaction:
My suspected diagnosis or condition
The nature, purpose, and potential benefit of the proposed care
The inherent risks, complications, potential hazards, or side effects of the treatment
The probability or likelihood of success
Reasonable available alternatives to the proposed treatment
The possible consequences if treatment or advice is not followed, or if nothing is done
I further acknowledge that no guarantees or assurances have been made to me concerning the results of this treatment.
I assume full liability for any adverse effects that may result from the non-negligent administration of this therapy. I waive any claim in law or equity for any grievance I may have concerning or resulting from this therapy, except where that grievance pertains to the negligent administration of the therapy.
I verify that all information I have provided regarding my medical history is true and complete to the best of my knowledge, and that I am not misrepresenting my current health status or medical history.
By signing below, I confirm that: I have been informed of my rights, I understand the therapy I am about to receive, I authorize and consent to this therapy, and I acknowledge that ozone therapy is NOT approved by the FDA and is considered experimental.
I fully understand and accept the possible risks in exchange for the possible benefits of this therapy. I agree to release and hold harmless Kōena Integrative Medicine's practitioners, consultants, associates, and staff from liability associated with the procedure(s) I receive, except as noted above regarding negligent administration. I confirm I have sought this treatment voluntarily and have not been forced to do so.