There is no guarantee that intravenous (IV) hydration therapy will help you achieve relief from hangover effects, migraines, lack of energy, or illness. These symptoms vary greatly and individual results will vary. While many feel relief from hydration therapy, symptoms may return within the first 24 hours of treatment.

Please drink alcohol in moderation. Excessive drinking after IV therapy can result in stomach irritation and other complications. Do not ever drink to excess with the assumption that IV hydration will be able to relieve your symptoms. Excessive drinking can lead to alcohol poisoning and other serious medical problems. Alcohol poisoning is a very serious, deadly condition. Always drink alcohol in moderation.

I hereby grant permission to be treated for my symptoms, including, but not limited to: dehydration, headache, nausea, and vitamin deficiency. I understand that this treatment may involve an intravenous catheter (an “IV”) and/or intramuscular injection and/or subcutaneous injection (each of the intramuscular and subcutaneous injections, an “Injection”). I understand that medical treatment has risks. The most common risks from IV hydration therapy include, but are not limited to: allergic reaction to medications, vein irritation, heartburn, fluid overload, kidney problems, headache, and pain at the IV insertion or Injection site. The more rare side effects include, but are not limited to: inflammation of the vein used for injection, phlebitis, metabolic disturbances and injury. The extremely rare side effects include, but are not limited to: severe allergic reaction, anaphylaxis, infection, and cardiac arrest. I have informed the nurse and/or other licensed medical profession (each, a “medical professional”) of any known allergies to drugs or other substances or of any past reactions to anesthetics. I have informed the medical professional of all current medications and supplements. 

Vitamin injections maintain good health and have been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes. Vitamin injections are better absorbed by the body since they go directly into the bloodstream. Alternatives to vitamin injections are oral vitamins, patches, lozenges, liquid drops, and nasal spray.

1. Risks: I understand there is a risk of mild 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, headache and joint pain.

2. If any of these side effects become severe or troublesome, I will contact my physician immediately.

3. I understand that although rare, vitamin injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin injections should be aware of the possibility. Uncommon side effects include: ∙ rapid heartbeat ∙ chest pain ∙ flushed face ∙ muscle cramps and weakness ∙ difficulty breathing and swallowing ∙ dizziness ∙ confusion ∙ tight feelings in the chest ∙ hives, skin rashes ∙ shortness of breath when there is no physical exertion and unusual wheezing, and ∙ coughing.

4. Before starting Vitamin injections, I will make sure to tell the practitioner if I am pregnant, lactating, or have any of the following conditions ∙ Leber’s disease ∙ Kidney disease ∙ Liver disease ∙ An infection ∙ Iron deficiency ∙ Folic acid deficiency ∙ Receiving any treatment that has an effect on bone marrow ∙ Taking any medication that has an effect on bone marrow ∙ An allergy to cobalt or any other medication, vitamin, dye, food or preservative.

5. 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 injection.

I have read the above information about the injections. I understand the benefits and risks of taking Vitamin injections. Knowing and understanding the risks involved with participation in Vitamin injections, I hereby voluntarily and willingly assume responsibility for all the risks associated with my participation in Vitamin injections. I release HydraDrip and their nurses, doctors, employees, directors, officers, and agents from any and all liability arising from or in connection with the Vitamin injection and hereby forever release, hold harmless, and discharge HydraDrip and the officers.

I understand that vitamins and nutritional supplements are not intended to diagnose, treat, cure, or prevent any diseases or illnesses.

I understand that HydraDrip does not offer Acute/Urgent Care Services or Primary Care Provider Services. I understand if at any time I am faced with a medical emergency I will contact Emergency Medical Services by dialing 911.

• I am aware that other unforeseeable conditions could occur. I do not expect the medical professional(s) to anticipate and/or explain all risks and possible complications. I rely on the medical professional(s) to exercise judgment during the course of treatment.
• I acknowledge that I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications and consequences associated with the procedure. My questions have all been answered in terms I understand. I am aware of the risks and potential side effects if I undergo IV hydration therapy.
• I have truthfully answered all questions regarding my medical history and have informed the staff about any and all prescription and/or over-the-counter drugs I take, as well as any street or recreational drugs. I understand that failing to inform the staff about my medical issues and drug use can lead to serious complications.
• I acknowledge that I am responsible for any medical care I have directly or indirectly related to my IV hydration therapy treatment. If there is an allergic reaction or otherwise, I agree that I am responsible for payment of my medical care.
• I represent and warrant that I understand the risks associated with hydration therapy. I hereby waive any and all claims and agree to hold HydraDrip (“HydraDrip LLC”) harmless regarding any adverse reaction(s) I may have during or following the IV hydration therapy treatment.

I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND ALL MY QUESTIONS HAVE BEEN ANSWERED, I understand I should not sign this form if IV hydration/nutritional therapy, its possible risks, and its possible benefits have not been explained to my satisfaction. I further understand that I should not sign this form if I have unanswered questions or if I do not understand anything in the consent form.

 

I give HydraDrip my informed consent to administer intravenous nutritional therapy.

Agreement to Arbitrate. It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Georgia/Tennessee law and not by a lawsuit or resort to court process of any form, except as Georgia/Tennesse law provides for judicial review of arbitration proceedings. Both parties to this contract, evidenced by patient’s signature below and HydraDrip acceptance of such signature, are voluntarily waiving their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration.

All Claims Must be Arbitrated. It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies, whether lying in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by any physician, nurse practitioner, nurse, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers affiliated with HydraDrip (collectively herein referred to as “Company”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Company of any action in any court by the Company to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Company, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Procedures and Applicable Law. A notice or demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Company, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his or her attorney. The parties shall thereafter select a mutually agreeable arbitrator to preside over the matter. The parties shall bear their own costs, fees and expenses, along with a pro rata share of the arbitrator’s fees and expenses.

Severability Provision. In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of this agreement enforced in accordance with Georgia/Tennessee State and federal law.

My signature below confirms that:

I am 18 years or older and am of sound legal mind to authorize and consent to the use of IV hydration therapy.

I have disclosed all known medical conditions, medications, and any other physical or mental conditions that I have or previously had. 

The procedure set forth above has been adequately explained to me by my attending medical professional.

I have received all the information and explanation I desire concerning the procedure.

This document is intended to serve as confirmation of informed consent for IV hydration therapy.

** If a staff member experiences a needle stick injury with potential for blood-to-blood transmission with participant, the participant agrees to obtain formal blood testing to rule out potential of communicable disease transmission via OSHA standards (HIV Hepatitis, etc).  HydraDrip assumes all costs of further necessary testing.  Testing shall be performed within 24 hours of needle stick injury at a nearby lab location. 

** HydraDrip reserves the right to refuse to initiate or continue IV treatment at  any time based on RN or staff discretion.