Emergency Contact Information:

Why are you visiting Rose Gold Care Med Spa LLC today? Please place "X" on all that apply.

List Current Medications and Current Dosage (Including all prescription, over the counter, herbs, vitamins, and supplements) below:

1. Have you been hospitalized or under the care of a physician in the past month?

2. Congestive Heart Failure Liver Disease

3. Do you currently take a blood thinner?

4. Do you currently take or use any type of steroid?

If you answered ("Yes") to any of the above questions 1-4, it may be advised by the Medical Director that you not receive IV Fluids, and you may be denied services.

I understand that participating in the intravenous (IV) hydration and vitamin administration services provided by Rose Gold Care Med Spa LLC carries risks.

I have truthfully answered all questions regarding my medical history and have informed the staff about any and all prescription medications 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/or drug use can lead to serious complications.

I acknowledge that I am responsible for any medical care I may have that is directly or indirectly related to the services provided by Rose Gold Care Med Spa LLC. If I seek medical treatment for any side effect or reaction, it will be at my own expense.

I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my voluntary participation in Rose Gold Care Med Spa's services rests entirely with me to the extent that I fail to disclose my health condition(s), medications, or drug use in advance of the services provided.

I expressly represent and warrant to Rose Gold Care Med Spa LLC that I have never been diagnosed with or treated for any illnesses or conditions that may result in increased risk when participating in the services provided byRose Gold Care Med Spa LLC. I understand that Rose Gold Care Med Spa LLC bears no responsibility for and will not screen for, diagnose, monitor, or provide any care for such conditions.

I acknowledge that Rose Gold Care Med Spa LLC relies upon information provided by me in assessing my ability to participate in the services provided.

There is no guarantee that hydration therapy will temporarily or permanently cure or resolve your hangover, effects of altitude sickness, dehydration, or viral illness.

Please drink alcohol in moderation. Heavy drinking after hydration therapy can lead to stomach irritation or other complications.

Hydration therapy is not a cure for heavy drinking. Excessive drinking can lead to alcohol poisoning and other serious medical problems. Always drink alcohol in moderation.

Rose Gold Care Med Spa is not a medical clinic. If you feel that you need medical attention or are concerned about a new or ongoing medical problem, please go to the nearest emergency department or call 911.

IV HYDRATION RISKS INCLUDE THE FOLLOWING:

Injury Bleeding Infection Inflammation/Swelling Extravasation

Misplacement of IV lines in the body Air Embolism

Fluid overload Adverse interactions with medications

Damage to surrounding structures (temporary or permanent) due to placement of IV

Nerve injury Lightheadedness or fainting Bruising or scarring from insertion of

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 procedures. I am aware that it is impossible to foresee or predict all possible risks, complications, and consequences, and I do not expect that the staff to anticipate or explain all associated risks.

I waive any and all claims related to the services provided and agree to hold Rose Gold Care Med Spa LLC harmless regarding any complications or consequences I experience during or following the service.

ARBITRATION AGREEMENT-READ CAREFULLY

It is understood and agreed by Rose Gold Care Med Spa LLC and as a recipient of services, that any legal dispute, controversy, demand, or claim that arises out of or relates to the services provided to me by Rose Gold Care Med Spa LLC or any other service provided by Rose Gold Care Med Spa LLC to me shall be resolved exclusively by binding arbitration to be conducted at a place agreed upon by the parties, in accordance with the American Health Lawyers Association (AHLA) Alternative Dispute Resolution Service Rules of Procedure for Arbitration, which are hereby incorporated into this agreement.

It is understood that any dispute as to medical malpractice (whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompletely rendered) will be determined by submission to arbitration and not in a court of law or before a jury.

It is the intent of the parties that this agreement cover all existing or subsequent claims or controversies, whether in tort, contract, or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to the treatment or

services provided or not provided by any employee, physician, association, partner, or agent affiliated with Rose Gold Care Med Spa LLC to a patient. This party includes causes of action that might be brought on behalf of me by a spouse, heir, child (born or unborn), guardian, or parent.

My signature below confirms that:

I HAVE READ AND UNDERSTAND THE ABOVE ARBITRATION AGREEMENT.

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

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

I have received all of the information that I desire regarding hydration therapy.

This document services as an informed consent for hydration therapy.

This party agrees that this agreement may be electronically signed.