INFORMED CONSENT
CLIENT REPRESENTATIONS / WARRANTIES & DISCLAIMER AGREEMENT:

Informed Consent / Participants Risks:

I understand that participating in intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, programs and services made available by IV Cleanse carries risks.

I ACKNOWLEDGE AND AGREE THAT THE SOLE RISK OF INJURY OR HARM RESULTING IN ANY MANNER FROM MY CHOOSING TO PARTICIPATE IN SUCH REGIMEN, PROGRAMS AND SERVICES RESTS ENTIRELY WITH ME TO THE EXTENT THAT I DO NOT DISCLOSE MY HEALTH CONDITIONS, MEDICATIONS OR DRUG USE IN ADVANCE.

I expressly represent and warrant to IV Cleanse that I have never been diagnosed with nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in regimens, programs or services made available by IV CLEANSE, and I am not choosing to participate with any expectation that IV Cleanse will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.

I acknowledge and understand that IV Cleanse is relying upon the foregoing representations and warranties from me upon IV CLEANSE’s acceptance of me for participation in its intravenous hydrations/therapies, programs and services.

RISKS INCLUDE THE SOME OF THE FOLLOWING AND MORE CAN BE FOUND IN THE TERMS AND CONDITIONS SECTION WHICH WILL NEED TO BE AGREED TO PIROR TO RECEIVING ANY SERVICES AND/OR PRODUCTS, OR PROGRAMS:

INJURY, BLEEDING, INFECTION, INFLAMMATION/SWELLING, BRUISING OR SCARRING RESULTING FROM IV INFILTRATION, EXTRACTION AND EXTRAVASATION

MISPLACEMENT OF IV LINES IN THE BODY AIR EMBOLISM
FLUID OVERLOAD
MEDICATION ADVERSE INTERACTIONS NERVE INJURIES

LIGHTHEADEDNESS OR FAINTING WARNING!

YOU EXPRESSLY REPRESENT AND WARRANT TO IV CLEANSE THAT YOU ARE NOT A USER OF ILLEGAL DRUGS AND/OR CONTROLLED SUBSTANCES AND ARE NOT UNDER THE INFLUENCE OF SAME OR RECOVERING FROM USE OF SAME AT THE TIME OF THE PROVISION OF SERVICES TO YOU.

IN THE EVENT OF AN EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM.

ACKNOWLEDGMENT: I confirm that I have read this form and have read the TERMS AND CONDITIONS SECTION and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by IV Clenase. I understand the nature of the sessions and programs and that

participating in them carries risks. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction. I agree to my assumption of all risks associated with my participation.

Patient Authorization for Use and Disclosure of Protected Health Information

By signing, I authorize IV Cleanse & MV Wellness NP in Family Health P.C to use and/or disclose certain protected health information (PHI) about me if needed.

This authorization permits IV Cleanse to use and/or disclose the following individually identifiable health information about me include, but are not limited to:

Date(s) of services, type of services, origin of information, age, gender, vital signs

The information will be used or disclosed for the following purpose:

Obtaining research data to reflect our growth, sales, and types of services requested by our client population.

The purpose is provided so that I can make an informed decision whether to allow release of the information. This authorization will expire one (1) year from date of service.

The Practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.
I do not have to agree to this authorization in order to receive treatment from IV CLEANSE. In fact, I have the right to refuse to agree to this authorization. IV Cleanse has the right to refuse services if consents are not agreed to.

When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization.

TERMS AND CONDITIONS

TERMS CONDITIONS OF SERVICES, PAYMENT & CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION.

By booking the services, you are agreeing to the following Terms and Conditions of our engagement. The services recipient is referred to herein as “client” or “you”. These terms to which you agree are referred to as “Terms and Conditions” or “Agreement”.

Insurance Not Accepted; Client’s Responsibility for Payment.

CLIENT UNDERSTANDS AND ACKNOWLEDGES THAT IV CLEANSE AND ITS PERSONNEL ARE NOT PAID OR REIMBURSED FOR THE SERVICES AND HANGOVER MANAGEMENT PROGRAM OR SUPPLEMENTS, VITAMINS OR PHARMACEUTICALS OFFERED BY IV CLEANSE BY MANAGED CARE PLANS, MEDICARE, MEDICAID, OR OTHER THIRD PARTY PAYOR PROGRAMS INCLUDING YOUR HEALTH INSURANCE CARRIER, AND DO NOT ACCEPT INSURANCE FOR SUCH SERVICES.

Clients will be BILLED DIRECTLY and shall be personally responsible for payment, regardless of whether clients are reimbursed by their insurance company, managed care plan or other third party payer.

IV CLEANSE does NOT diagnose or treat any illness, disease or health condition.

Upon entering into these Terms and Conditions, you expressly represent and warrant that you are not engaging IV CLEANSE or its personnel with the expectation that it or they will diagnose or otherwise provide treatment for any illness, disease or condition of any nature. IV CLEANSE personnel will not screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions. IV CLEANSE is relying upon the foregoing representations and warranties upon your entering into these Terms and Conditions and upon IV CLEANSE acceptance of you for the provision of services.

I hereby give my consent for IV CLEANSE to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO) (The Notice of Privacy Practices provided by IV CLEANSE describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to agreeing to this consent. IV Cleanse reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to IV Cleanse. With this consent, IV CLEANSE may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, IV Cleanse may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.” With this consent, IV Cleanse may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that IV Cleanse restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, IV Cleanse may decline to provide treatment to me.

By signing this form below, I am consenting to allow IV Cleanse to use and disclose my PHI to carry out TPO.

INFORMED CONSENT, CLIENT REPRESENTATIONS/WARRANTIES & DISCLAIMER AGREEMENT

I understand that participating in intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, programs and services made available by IV Cleanse carries risks.

I ACKNOWLEDGE AND AGREE THAT THE SOLE RISK OF INJURY OR HARM RESULTING IN ANY MANNER FROM MY CHOOSING TO PARTICIPATE IN SUCH REGIMEN, PROGRAMS AND SERVICES RESTS ENTIRELY WITH ME TO THE EXTENT THAT I DO NOT DISCLOSE MY HEALTH CONDITIONS, MEDICATIONS OR DRUG USE IN ADVANCE.

I expressly represent and warrant to IV Cleanse that I have never been diagnosed with nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in regimens, programs or services made available by IV Cleanse, and I am not choosing to participate with any expectation that IV Cleanse will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.

I acknowledge and understand that IV Cleanse is relying upon the foregoing representations and warranties from me upon IV Cleanse acceptance of me for participation in its intravenous hydration, programs and services.
I acknowledge and understand that IV Cleanse is not responsible or liable for any complications that result from the use of any client provided or custom requested vitamins, injections, or medication.

RISKS INCLUDE THE FOLLOWING:

INJURY, BLEEDING, INFECTION, INFLAMMATION/SWELLING, BRUISING OR SCARRING RESULTING FROM IV INFILTRATION, EXTRACTION, EXTRAVASATION AND INJECTION, MISPLACEMENT OF IV LINES IN THE BODY, AIR EMBOLISM, FLUID OVERLOAD, MEDICATION ADVERSE INTERACTIONS, NERVE INJURIES,

LIGHTHEADEDNESS OR FAINTING, PAIN OR BURNING DURING INJECTION OTHER RISKS CAN INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING:

Risks: I understand there is risk of diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, infections, headache and joint pain, IV infiltration, extravasation.

If any of these side effects become severe or troublesome, I will contact my physician immediately or go to the emergency department.

I understand that Vitamin Infusions/injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking Vitamin Infusions/injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of vitamin infusions and/or injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:

headache • nausea • diarrhea • bloating • constipation • indigestion or heartburn • abnormal bleeding
• gastrointestinal hyperactivity • chest pain • flushed face • chills • fever • upset stomach • kidney stones
• fingernail weakening • hair loss • rapid heartbeat • heart palpitations • restlessness • muscle cramps
• weakness • dizziness • sepsis

I understand the possibility of having an allergic reaction to any of the ingredients found within the Vitamin injection/infusions is quite plausible and that I should communicate with my Physician if I have any known allergic reactions to foods, dyes, preservatives, or anyother substances. If I experience any of these following signs of allergic reactions I should immediately consult my primary health care Physician and discontinue further use of the product.

Signs of allergic reactions include, but not limited to:

 Itching of skin • Hives • Rashes • Wheezing • Difficulty breathing • Swelling of mouth or throat

When medications are taken in conjunction with the Vitamin Infusions/Injection, drug interactions could occur. These interactions can either increase your risk of bleeding or block the absorption of the Vitamins into the body. These medications at the time of your Infusion or injection should either be discontinued or be consulted with by a Physician. Some of the medications that may cause drug interactions include, but are not limited to:

Heparin (Fragmin, Lovenox, Innohep...ect.) • Antithrombin (A Tryn, Thrombate III)
• Argatroban • Aspirin • Ibuprofen • Dipyridamole (Persantine) • Bivalirudin (Angiomax)

• Clopidogrel (Plavix) • Warfarin (Coumadin, Jantoven) • Nonsteroidal anti-inflammatory
drugs (Ibuprofen,...etc.)

Before starting the Vitamin infusions/injections I will make sure to tell the clinician, nurse and/or Physician if I am pregnant, lactating or have any of the following conditions.

Leber’s Disease

•   Kidney disease

•   History of Kidney stones

•   Liver disease

•   Hormonal disease

•   Cardiovascular disease

•   History of ulcers

•   History of gastrointestinal problems

•   Bipolar disorder (manic depression)

•   Attention Deficit Hyperactivity Disorder (ADHD)

•   Muscular Dystrophy

•   Elliptic seizures

•   Hypoglycemia

•   Schizophrenia

•   Benign prostatic hypertrophy (BPH)

•   Acetaminophen poisoning

•   Hypertension (high blood pressure)

•   History of seizures

•   Under-active thyroid (hypothyroidism)

•   Osteoporosis

•   Receiving treatment or taking any medication that might “thin” the blood

•   Receiving treatment or taking medication that has an effect on bone

  marrow

•  An infection

•   Iron deficiency

•   Folic acid deficiency

•   Dependent on intravenous nutrition (TPN) or liquid nutrition products for

  food

•   Diabetes, mellitus, or high blood sugar levels

•   An unusual or allergic reaction other medicines, foods, dyes, or

  preservatives

  I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may result in side effects when they interact with the Vitamin Infusion/Injection.

  YOU EXPRESSLY REPRESENT AND WARRANT TO IV Cleanse THAT YOU ARE NOT A USER OF ILLEGAL DRUGS AND/OR CONTROLLED SUBSTANCES AND ARE NOT UNDER THE INFLUENCE OF SAME OR RECOVERING FROM USE OF SAME AT THE TIME OF THE PROVISION OF SERVICES TO YOU.

IN THE EVENT OF AN EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM.

ACKNOWLEDGMENT: I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by IV Cleanse. I understand the nature of the sessions and programs and that participating in them carries risks. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction. I agree to my assumption of all risks associated with my participation.

I have read the above consent form and terms and conditions, do agree with these terms and consent to participate in the IV Cleanse program

 

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