Consent & Medical History

Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Are you a first-time client?*

Has your medical history changed since your last visit?*

How did you hear about us?

What services are you interested in today?

Has your address changed?*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Has your email address changed?*

Email*

example@example.com

Confirm Email*

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Drip into Wellness Informed Consent and Arbitraion Agreement

Drip into Wellness cannot guarantee any results from the use of intravenous therapy (IV Therapy) and/ or intramuscular injection (each of the intramuscular injection, an "injection"). I agree and acknowledge that no promises have been made regarding the efficacy of IV Therapy or Injection and that this treatment is not a substitute, cure, therapy, or treatment for any disease or condition.

IV Therapy or Injection Procedure

The IV Therapy Procedure involves inserting a needle into the vein and infusing or injectioning a solution of nutrients (vitamins, minerals, amino acids, glutathione, electrolytes, sugars, and diluents) over a period of time. IV Therapy is a means to deliver vitamins, minerals, and other nutrients to the body while avoiding the digestive process. This is helpful in many cases where clients are depleted of certain nutrients and is especially helpful in conditions of decreased intestinal absorption of nutrients.

Drip into Wellness cannot guarantee that IV Therapy or Injections will help you achieve relief from hangover effects, migraines, or lack of energy. These symptoms vary greatly and individual results will vary. While many feel relief from IV Therapy or Injection, symptoms may return within the first 24hours of treatment and some conditions may benefit from more that one treatment.

Use of Alcohol

In order to aid the treatment, please drink alcohol in moderation. Excessive drinking after IV Therapy or Injection can result in stomach irritation and other complications. Do not ever drink to excess with the assumption that IV Therapy or Injection 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 in moderation.

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Drip into Wellness Informed Consent and Arbitraion Agreement

Drip into Wellness cannot guarantee any results from the use of intravenous therapy (IV Therapy) and/ or intramuscular injection (each of the intramuscular injection, an "injection"). I agree and acknowledge that no promises have been made regarding the efficacy of IV Therapy or Injection and that this treatment is not a substitute, cure, therapy, or treatment for any disease or condition.

IV Therapy or Injection Procedure

The IV Therapy Procedure involves inserting a needle into the vein and infusing or injectioning a solution of nutrients (vitamins, minerals, amino acids, glutathione, electrolytes, sugars, and diluents) over a period of time. IV Therapy is a means to deliver vitamins, minerals, and other nutrients to the body while avoiding the digestive process. This is helpful in many cases where clients are depleted of certain nutrients and is especially helpful in conditions of decreased intestinal absorption of nutrients.

Drip into Wellness cannot guarantee that IV Therapy or Injections will help you achieve relief from hangover effects, migraines, or lack of energy. These symptoms vary greatly and individual results will vary. While many feel relief from IV Therapy or Injection, symptoms may return within the first 24hours of treatment and some conditions may benefit from more that one treatment.

Use of Alcohol

In order to aid the treatment, please drink alcohol in moderation. Excessive drinking after IV Therapy or Injection can result in stomach irriation and other complications. Do not ever drink to excess iwththe assumption that IV Therapy or Injection 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 in moderation.

Potential Side Effects and Risks from Injections include but are not limited to:

Tenderness or Bruise at injection site
Allergic Reaction
Infection at injection site as with all injections

Contraindications for IV Therapy or Injections may include, but are not limited to:

Known liver and /or kidney dysfunction
Know heart disease
G6PD deficiency
Pregnancy or Breastfeeding

Initial*

I, the undersigned, hereby grant Drip into Wellness the absolute right and permission to use my photograph(s) in any manner or media, including, but not limited to, the following purposes:

Educational materials
Publications
Advertising and promotional materials
Social media platforms
Websites
Press releases

No Compensation

I understand that I will not receive any monetary compensation for the use of my photograph(s).

Rights Granted

I grant Drip into Wellness the following rights:

The right to edit, alter, copy, or distribute the photograph(s) for any lawful purpose.
The right to use my name in connection with the photograph(s) if they choose.

Release and Waiver

I hereby release and discharge Drip into Wellness, its employees, agents, and representatives from any and all claims, demands, or causes of action that I may have now or in the future for defamation, invasion of privacy, or violation of the right of publicity or any other right arising out of or relating to the use of the photograph(s).

By signing below, I acknowledge that I have read and understood this Permission to Use Photo Release Form and agree to the terms and conditions stated above.

Signature

Acknowledgements

I understand that the following actvities will reduce the efficacy of IV Therapy or Injections:

Cigarette smoking, including vaping
Certain Medications
Caffeine consumption
Poor diet: high sugar intake, processed foods, nutrient deficient diets
Heavy metal toxicity

Initial*

I have informed Drip into Wellness 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 (both prescribed & over-the-counter) and supplements.

I will notify Drip into Wellness before any treatments are performed, of any changes in my medical history, allergies, or medications/supplements. I will be hydrated and eat a snack or meal before receiving IV Therapy or Injection.

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 understand that it is my responsibility to inform the staff providing IV Therapy or injection immediately if I feel any discomfort or sensation that is unusual. I rely on the medical professional(s) to exercise judgment during the course of treatment, including the discontinuation 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. I understand that the nature and purpose of IV Therapy or Injection may be considered unproven by scientific testing and peer- reviewed publications and therefore may be considered by some physicians to be medically unnecessary and not the standard of medical care for most conditions.

I 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.

My questions have all been answered in terms I understand. I am aware of the risks and potential side effects if I undergo IV Therapy or Injections

Initial*

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.

Initial*

I acknowledge that I am responsible for any medical care I have directly or indirectly related to my IV Therapy or Injection treatment. If there is an allergic reaction or otherwise, I agree that I am responsible for payment of my medical care.

Initial*

Waiver of Claims

I represent and warrant that I understand the risks associated with IV Therapy or Injection. I hereby waive any and all claims and agree to hold Southern Advocate LLC d/b/a Drip into Wellness harmless regarding any adverse reaction(s) I may have during or following the IV Therapy or Injection treatment.

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Arbitration Agreement

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 the law of the state or jurisdiction where this service is performed, and not by a lawsuit or resort to court process of any form, except as the law of the state or jurisdiction where this service is performed provides for judicial review of arbitration proceedings. Both parties to this contract, evidenced by patient’s signature below and Drip into Wellness’ 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 Drip into Wellness (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 state and federal law.

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Payment

Payment is due at the time of service unless otherwise agreed by Drip into Wellness. There has been no representation that this procedure is covered under my insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless if the IV Therapy or Injection is cancelled or is stopped at any time prior to completion at the discretion of Drip into Wellness staff, medical director, or myself. I understand that I am responsible for the full cost of the procedure and agree to pay.

Refunds

There are no refunds on concierge fees in the event you are not a candidate for IV therapy or the nurse is unable to gain intravenous access. The cost of the IV therapy/drip purchased will be refunded. There is NO refunds for injections (shots) or shot bundles. There are no refunds for gift certificates. There are no refunds for IV Therapy or Shot Injection Memberships.

Cancellation Policy

We require a 24 hour Advance notice for cancellations. You will be charged the concierge fee should you not provide at least 24 hour notice. Group appointments (parties of 2 or more) will be charged 50% of the booked service & concierge fee should you not provide at least a 24 hour notice. All appointments outside of mobile IV Therapy are subject to a late cancellation fee of $50. We require a 24hour advanced notice for cancellations and ask that you please reschedule your appointment within one hour of your appointment beginning or you may be charged a cancellation fee.

Initial*

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 Therapy or Injection.

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 Therapy or injection.

Date*

Date

Signature*

Are there any current health conditions or concerns?

Curent Medications:

YesNo

Allergies: (medication, dyes, latex, or food)

Details of conditions marked above:

YesNo

** If you have any of the conditions mentioned above you may not be medically approved for IV Therapy or Injection. Your nurse will discuss this with you before continuing.

Signature*

Has your emergency contact information changed?*

Emergency Contact's Name:*

First NameLast Name

Emergency Contact's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Drip into Wellness reserves the right to refuse to initiate or continue any IV therapy treatment at any time based on the RN or staff’s discretion.

By signing below, I hereby agree that all of the above information is true and accurate to the best of my knowledge.

Questions/ Concerns/ Comments

Signature*

agree

Informed Consent & Arbitration Agreement

Permission to Use Photo

Medical History Form

Emergency Contact Information