RevIVed Consent Form

Consent Form
INFORMED CONSENT REVIVED MOBILE INFUSIONS

I give consent to REVIVED MOBILE INFUSIONS to administer vitamins, minerals, medications, and other nutrients via injection and/or intravenously. I understand that intravenous nutrient therapy is not approved or accepted for the purpose(s) of treatment or prevention of disease. I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, exercise, and proper diet). I have informed REVIVED MOBILE INFUSIONS of all of my current medications and supplements that I am taking as well as any health problems and allergies. As with any other medical procedure, a small percentage of clients do not respond to this therapy. I have been informed of possible risks and side effects including but not limited to discomfort and bruising at the injection site, infection, bleeding, thrombophlebitis, fatigue, congestive heart failure, metabolic disturbances, anaphylaxis, cardiac arrest, or death. I understand the nature of the proposed therapy and the risks involved have been explained to my full satisfaction. Benefits of intravenous therapy include nutrients bypassing the stomach and not being disturbed by intestinal absorption. This process allows nutrients to be available to the tissues by means of a high concentration gradient. I understand that this treatment is voluntary and I may terminate it at any time. I acknowledge that REVIVED MOBILE INFUSIONS is self-pay only, and does not accept Medicare, Medicaid, or any other private insurance. I am responsible for full payment at the time of service or otherwise agreed by previous arrangements between myself and REVIVED MOBILE INFUSIONS. I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations, and materials that may be provided to me for education. I acknowledge that I have had the opportunity to ask questions, and all of my questions have been answered to my full satisfaction. My agreement will constitute a full and final release of any legal responsibility of REVIVED MOBILE INFUSIONS and all associated before, during, and following my treatment, and in my case and/or any other medical treatments that may be necessary as a result thereof. My agreement confirms that I am 18 years of age or older, and of sound mind. I have read, understood, and agree to this consent, and to receive treatment. All of my questions have been answered to my full satisfaction.
PURPOSE

The purpose of this form is to obtain your consent for: Health and wellness services administered by REVIVED MOBILE INFUSIONS and its affiliates. These services are being provided by: REVIVED MOBILE INFUSIONS and its affiliates. The reason these services are being provided is: General Health and Wellness.
NATURE OF THE SERVICES

The REVIVED MOBILE INFUSION services consist of infusions into my body through IV drip or IM injection, of minerals, vitamins, and/or other nutrients suspended in a liquid form. A needle and or a needle and a catheter will be inserted through my skin either into a muscle or a vein in order to introduce this liquid into my body.
RISKS, BENEFITS AND ALTERNATIVES

The benefits of the Services include potentially: increased energy, hydration, increase in metabolism, cardiovascular support, nail, skin and hair health, and immune-system support. The risks include: (i) injection/venipuncture site swelling, redness, irritation, bruising, bleeding, and infection, (ii) reaction to vitamins including fever, aches, nausea, rash, hives, wheezing, joint swelling, and general allergic reaction, and (iii) other minor complications of IV or IM injection.
NON-FDA EVALUATED OR APPROVED

I, as patient signing and consenting below, understand and acknowledge that the United States Food and Drug Administration has not evaluated or approved the treatments I am about to receive to diagnose, treat, cure, or prevent any disease. The FDA might in fact recommend other treatments.
JUDGEMENT AND CHANCE TO ASK QUESTIONS

In giving the consent hereunder, I, as patient, am relying on the judgment of the clinical professional evaluating me and administering the treatments. I have had the meaningful chance to ask questions and have received satisfactory answers to my questions. The risks and potential benefits of the treatment I am consenting to have been explained to me. Alternatives to the treatments I am consenting to have also been discussed with me.
MEDIA RELEASE

I hereby grant permission to REVIVED MOBILE INFUSIONS to use photographs and/or videos obtained from me for advertising purposes.
PAYMENT

I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.
CONTACT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HEIGTH FEET* INCHES*
WEIGHT lbs*
Gender*
PATIENT HISTORY

We need to gather some information about you & your health. Your answers will be evaluated by a licensed healthcare professional to determine if treatment is appropriate for you at this time.
ALLERGIES?*
IF YES, LIST YOUR DRUG ALLERGIES
MEDICATIONS?*
IF YES, LIST YOUR CURRENT MEDICATIONS
CURRENTLY SICK?*
IF YES, LIST YOUR SYMPTOMS (nausea, vomiting, dehydration, cough, fever, etc)
PREGNANT?*
BREASTFEEDING?*
DIABETIC?*
DO YOU HAVE HEART DISEASE?*
DO YOU HAVE KIDNEY DISEASE?*
DO YOU HAVE LIVER DISEASE?*
Were you referred by someone?
Are you part of a group or company getting infusions? If so, which company or who organized the group?
HIPPA AGREEMENT

Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent We may use and disclose your Protected Health Information as follows without your permission:

For treatment purposes. We may disclose your health information to doctors, nurses and others who provide your health care. For example, your information may be shared with people performing lab work or x-rays.

To obtain payment. We may disclose your health information in order to collect payment for your health care. For instance, we may release information to your insurance company.

For health care operations. We may use or disclose your health information in order to perform business functions like employee evaluations and improving the service we provide. We may disclose your information to students training with us. We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you.

When required by law. We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies. For example, we may have to report abuse, neglect or certain physical injuries.

For public health activities. We may be required to report your health information to government agencies to prevent or control disease or injury. We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety.

For health oversight activities. We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses.

For activities related to death. We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they can carry out duties related to your death, such as determining the cause of death or preparing your body for burial. We also may disclose your information to those involved with locating, storing or transplanting donor organs or tissue.

For studies. In order to serve our patient community, we may use or disclose your health information for research studies, but only after that use is approved by UWM's Institutional Review Board or a special privacy board. In most cases, your information will be used for studies only with your permission.

To avert a threat to health or safety. In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen that threat.

For specific government functions. In certain situations, we may disclose health information of military officers and veterans, to correctional facilities, to government benefit programs, and for national security reasons.
CONSENT

In considering all of the factors above, including risks, benefits and potential adverse results and reactions, and based on my conversations with my clinical professional about the same and alternative therapies, I hereby consent to examination, treatment, and IV therapies as listed above, including the placement of IV catheters or IM injections into and through my skin and/or veins and muscles by our medical director or the clinical professionals working under his direction. I release the medical staff including but not limited to the Dr. Nathan Holman, MD and Erin Decker, RN from any liability associated before, during, and after procedure. I have completed the form truthfully and to the best of my knowledge. I agree to inform the staff of any changes in the above information. I certify that I am a competent adult of at least 18 years of age and that this consent form is voluntarily executed.
FULL NAME (patient or parent/guardian)*
TODAY'S DATE*

MonthDayYear
Date
RN
RN Signature

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MD
MD Signature

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Consent Form

INFORMED CONSENT REVIVED MOBILE INFUSIONS

PURPOSE

NATURE OF THE SERVICES

RISKS, BENEFITS AND ALTERNATIVES

NON-FDA EVALUATED OR APPROVED

JUDGEMENT AND CHANCE TO ASK QUESTIONS

MEDIA RELEASE

PAYMENT

CONTACT INFORMATION

PATIENT HISTORY

CONSENT