La V Health Fusion
IV Hydration Consent
I consent to have my pictures and/or videos taken and stored in the electronic medical record system of La V Health Fusion. Such photographs and videos will not be used for any purpose except internal training without my express permission. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment prior to receiving services.
I further agree in the event of non-payment, cancellation of payment, or any payment issues, to bear the cost of collection, the court costs, and legal fees, should those be required.
I consent to email, text and phone communications related to post-treatment care and follow-up appointments. I consent to receive promotional messages and marketing messages via email, phone, and SMS messages from La V Health Fusion.
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing/breastfeeding). I do not have or have not had any major illnesses which would prohibit me from receiving this treatment. I have not had any dental treatments or vaccinations in the last 14 days.
I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to, vitamins and lidocaine. I am completely of sound mind and am fully aware of all the risks and possible complications of this treatment. I understand this treatment is one hundred percent voluntary. I acknowledge that no guarantee has been given regarding the results that may be obtained. I have read the material given to me and I am fully satisfied that all my questios and concerns have been addressed.
I have advised my provider of my medical history including all previous medical conditions and medications currently being taken by me. La V Health Fusion reserves the right to refuse to initiate or continue IV Hydration treatment at any time based on the Medical Director’s (or any other provider’s) discretion.
Alternatives to the treatments and options that I am choosing to get today have been fully explained to me. I am aware that there may be other risks or complications not discussed that may occur. I also understand that during the proposed treatment, unforeseen conditions may be revealed requiring the performance of additional treatments, and I authorize such treatments to be performed.
I acknowledge that no guarantees or promises have been made to me concerning the results of this treatment or any treatment that may be required because of this treatment. I understand there are no refunds and that multiple treatments are often required to achieve noticeable and lasting outcomes. I also understand that promotional items have no refund value.
IV Hydration is the process of injecting fluids into the body to hydrate from within. The fluids will include water and electrolytes, and salt or sugar to help with retention. To administer IV rehydration, the provider will insert an IV line into a vein into your arm. This IV line will consist of a tube with a needle on one end. The other end of the line will be connected to a bag of fluids, which will be hung above your head. The IV line will be checked periodically to ensure that the proper fluids are flowing. The length of treatment time will vary and will be discussed by your provider prior to treatment.
Possible adverse reactions (generally resolve within 21 days):
Injection site bruising/inflammation/swelling
Injection site pain
Swelling
Discoloration
Slight and adjustable nutrient imbalance
Injury bleeding
Extravasation of fluid
Misplacement of IV lines in the body
Air Embolism
Fluid overload
Adverse interactions with medications
Nerve injury
Lightheadedness or fainting
Damage to surrounding structures
Severe allergic reaction, anaphylaxis, cardiac arrest, and death
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.
This medicine is not for use in children.
BEFORE RECEIVING IV Hydration: Tell your healthcare provider about all your medical conditions, including if you:
Have been hospitalized or under the care of a physician in the past month
Have a medical history of:
Congestive Heart failure
Liver Disease
Kidney Disease
Renal Insufficiency
Are taking any type of steroid
Have bleeding problems or are taking blood thinners
Are pregnant or plan to become pregnant
Have an infection in the treatment area
If you answered (“Yes”) to any of the above questions it may be advised by the Medical Director that you not receive IV fluids, and you may be denied services.
Vitamin C Intravenous (IV) Infusion therapy
Purpose: The aim of Vitamin C IV infusion is to introduce high concentrations of Vitamin C directly into my bloodstream, providing therapeutic benefits such as enhancing immune function, supporting wound healing, and delivering antioxidant protection.
Procedure: A qualified healthcare professional will insert an IV catheter into a vein, typically in the arm, and administer the Vitamin C solution over a duration ranging from 30 minutes to 2 hours. The infusion may be given as a standalone treatment or as part of a series, depending on my medical condition and the healthcare provider's recommendations.
Risks and Side Effects: Although Vitamin C IV infusion is generally regarded as safe, there are potential risks and side effects, including, but not limited to:
a. Discomfort, swelling, or inflammation at the injection site
b. Infection or hematoma
c. Allergic reactions
d. Dizziness, lightheadedness, or fainting
e. Nausea or vomiting
f. Kidney stones or decreased kidney function (in rare instances, with high doses)
g. Excessive Vitamin C in the body
Contraindications: I am aware that Vitamin C IV infusion may not be appropriate in certain situations, such as:
a. Kidney disorders or a history of kidney stones
b. Hemochromatosis or other iron-overload conditions
c. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
d. Pregnancy or breastfeeding
Other Contraindications include:
Vitals signs outside of predetermined ranges as below:
SBP >150, DBP >100
HR>100 or
RR>24
Pulse Ox
I understand that participating in the intravenous (IV) hydration provided by La V Health Fusion carries risks.
I have truthfully answered all questions regarding my medical history and have informed the staff about 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 La V Health Fusion.
I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my voluntary participation in La V Health Fusion 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 La V Health Fusion that I have never been diagnosed with or treated or any illnesses or conditions that may result in increased risk when participating in the services provided by La V Health Fusion. I understand that La V Health Fusion bears no responsibility for and will not screen or, diagnose, monitor, or provide any care for such conditions.
I acknowledge that La V Health Fusion relies upon information provided by me in assessing my ability to participate in the services provided.
There is no guarantee that IV hydration therapy will temporarily or permanently cure or resolve your hangover, effects of altitude sickness, dehydration, viral illness, or athletic depletion.
Please drink alcohol in moderation. Heavy drinking after IV hydration therapy can lead to stomach irritation or other complications. IV hydration therapy is not a cure for heavy drinking.
La V Health Fusion 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.
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 treatments. I am aware that it is impossible to foresee or predict all possible risks, complications, and consequences, and I do not expect the staff to anticipate or explain all associated risks.
I waive all claims related to the services provided and agree to hold La V Health Fusion harmless regarding any complications or consequences I experience during or following the service.
Should a staff member have a needle stick injury with potential for blood-to-blood transmission with clients, client agrees to obtain formal blood testing to rule out potential of communicable disease transmission via OSHA standards (HIV, Hepatitis, etc.). La V Health Fusion assumes all costs of further necessary testing if incident is caused by staff. Testing shall be performed within 24 hours of the needle stick injury at a nearby lab facility.
Post-treatment I agree to comply with the following instructions:
Avoid manipulation of the treated area. Some redness, swelling, hematomas and bruising may occur following treatment. Resolution is typically spontaneous within a few days. As with all treatments that involve puncturing the skin, there is a risk of infection, granulomas, abscess formation and hypersensitive reaction. Persistence of any inflammatory reaction for more than one week or the development of any other side effects must be reported to the practitioner as soon as possible.
I understand some clients may experience a hypersensitive reaction to Hibiclens, alcohol, or acetone, or to other prep or cleaning solutions.
Consent for Mobile Services
I hereby consent to the performance of the treatment in a mobile setting. I have been explained the risks associated with mobile treatments and am voluntarily agreeing to receive the treatments outside of the Practice’s facilities for my convenience.
By accepting and signing, I acknowledge that I have read this informed consent, I understand it, and I agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the host, Medical Director(s), the La V Health Fusion provider performing the treatment and La V Health Fusion from liability associated with this treatment. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction.
I understand that because the provider is coming to my home and/or providing these services in a mobile environment with limited resources there are additional possible risks for the treatment.
Below is a list of potential risks associated with mobile services, but there could be others not mentioned in this form:
No standards for cleanliness in the home
Lack of resuscitation equipment
Improper disposal of medical waste
Lack of proper equipment to perform the treatment
Unpredictability of the environment
Unaccounted for distractions, such as pets in the home
No protocol in case of natural, or other, disasters
No ease of access to patient for provider
Lack of access to necessary medication in case of emergency
Lack of flexibility in treatment; provider can only do the treatment they were explicitly asked to perform and have supplies to perform, no add-ons.
Lighting inside the home may not be as bright as medical grade lighting.
Home surfaces have not been sanitized or sterilized.
I attest that I have not consumed any alcohol or other substance within the last 24 hours that would hinder my ability to consent to the treatment(s).
Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the host, La V Health Fusion and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.
I have fully disclosed on my patient intake form any medications, previous complications, or current conditions that may affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.
ARBITRATION AGREEMENT – READ CAREFULLY
It is understood and agreed by La V Health Fusion and I, 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 La V Health Fusion or any other service provided by La V Health Fusion to me shall be resolved exclusively by binding arbitration as provided by Florida law.
It is understood that any dispute as to medical malpractice and/or negligence (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 in 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 of services provided or not provided by any employee, physician, association, partner, or agent affiliated with La V Health Fusion to a patient. This includes any 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 read, write, and fully understand English. I am 18 years or older, of sound mind and body and have the full capacity to consent to this treatment.
The treatment set forth has been adequately explained to me by my attending medical professional. I have received all the information that I desire regarding my IV hydration therapy.
I hereby consent to the IV Hydration Treatment and hereby authorize the La V Health Fusion provider to perform the IV Hydration Treatment.
Severability
The provisions of this Consent shall be deemed severable and the invalidity or unenforceability of any one or more of the provisions hereof shall not affect the validity and enforceability of the other provisions hereof.
I am the treating doctor/healthcare professional (Provider). I discussed the above risks, benefits, and alternatives with the patient. The patient had an opportunity to have all questions answered and was offered a copy of this consent. The patient has been told to contact La V Health Fusion should they have any questions or concerns after this treatment.
Optional - Social Media and Promotional Release and Consent
I hereby give permission to La V Health Fusion to use my photo, video, and/or likeness in all forms of media, for the purpose of advertising, training, and any other lawful purposes. I also agree to receive marketing materials from La V Health Fusion including texts.