Infusion Center

I, hereby, give my permission for Rocky Mountain Infectious Diseases (Dr. Mark Dowell, Dr. Ghazi Ghanem, Dr. Martin Ellbogen, Dr. Alexandru David, Dr. Kara Willenburg, and Marsha Johnson APRN) to render treatment to me/my dependent. I have been given all available pertinent information, and the opportunity to ask questions, and these were answered to my satisfaction. At any time, during the course of therapy, it is my responsibility to ask for clarification of any aspects of the treatment plan that are unclear.

I acknowledge that I have been informed of the following information by a representative of Rocky Mountain Infectious Diseases:

• I am aware that infusion therapy is available through other providers, and I have a choice in providers, and have chosen to receive this treatment as an outpatient.
• I am aware that the outpatient infusion program is part of Rocky Mountain Infectious Diseases and is directed by the physicians, and that other alternative infusion centers may be available. If I choose an alternative infusion center this will not affect my status or rights as a patient of RMID.
• I have received instructions regarding potential adverse effects and risks related to infusion therapy and agree to immediately report side effects to the physician’s office.
• I have received verbal and written instructions regarding self-administration procedures (if applicable) and agree to participate.
• I and/or my designated care giver agree to follow the instructions provided by the Rocky Mountain Infectious Diseases staff as it pertains to medication administration, equipment related to infusion therapy, or care of my venous access device.
• I agree to follow up with the physician’s office for monitoring as requested.
• If I choose to receive infusion therapy in the physicians’ office I consent to have treatment administered in an open infusion space with other patients present.