The IV Lounge Consent for Direct Preventive Care
CONSENT FOR TREATMENT
I, as a patient, hereby authorize and give consent to licensed healthcare providers of IV Lounge, LLC under the medical direction of a licensed physician at the IV Lounge to perform intravenous (IV) access and /or Intramuscular (IM) therapy in the form of sterile solutions of fluids, vitamins and amino acids for the purposes of general well-being and hydration.
I have informed the licensed health care provider to the best of my knowledge, that I do NOT have any of the following, which may be contraindications to receiving IV therapy/certain services or medications:
• Heart or kidney failure of any kind
• Organ transplant
• Difficulty clotting/easy bruising/or current use of anticoagulants (blood thinners)
• Uncontrolled hypertension
• Hereditary Leber optic neuropathy
• Current alcohol or illicit drug intoxication
• Currently undergoing chemotherapy
IV Lounge, LLC healthcare provider informed me about the description and indication of the proposed procedure, as well as possible risks and side effects including but not limited to mild to moderate discomfort at the injection site, allergic reaction, congestive heart failure, lowering of the blood sugar level or blood pressure, irritation of the vein and generalized complaints.
I acknowledge that I have received no warranties or guarantees with respect to the benefits to be realized or the consequences of the IV therapy. I fully understand and accept the risks and side effects of the IV treatment including a remote possibility of severe allergic reaction and death from undiagnosed allergies to the administered treatment. As such, I agree in no way to hold IV Lounge, LLC and its licensed healthcare providers and employees responsible for any untoward consequences and subsequent outside medical care including and up to ambulance transport and/or hospitalization cost that may results from the above treatment.
I attest that I have read and fully understand this Consent Form and have opportunity to ask questions and discuss the nature, purpose and potential benefits as well as risks, complications and potential side effects of proposed treatment with a licensed healthcare provider of IV Lounge, LLC and give this Consent voluntarily. I understand that IV vitamin and hydration therapy is accepted by a minority of medical doctors and there are alternatives to IV therapy such as oral vitamins and nutritional supplements.
HIPAA COMPLIANCE STATEMENT: IV Lounge, LLC assures our customers that should your Protected Health Information (PHI) be made available to us, we will protect it and will not disclose it except in the circumstances required by law. We will comply with the rules and regulations concerning the privacy and security of PHI under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Also at the request and direction of the customer and if feasible, IV Lounge LLC will make available PHI in accordance within the requirement of HIPAA.
I understand that my results may be delivered via electronic format (ie. e-mail) and I am aware of and accept any and all risks associated with electronic transmission of my health information to include, but not limited to, transmission via unencrypted email. I understand that results will only be sent to the verified email address (es) on file from my patient registration forms). I understand that my results will also be accessible via an online patient portal (www.vista-clinical.com/ patient portal).
I, the undersigned; hereby voluntarily consent to medical care/diagnostic treatment and/or minor surgical treatment by "company" deemed advisable and necessary in the diagnosis and treatment of my condition. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatment or examination in this office.