Symptom Fixing Shot

When would you like your injection?*

Name*

First NameLast Name

Phone Number*

E-mail*

example@example.com

Service address for injection:

Which Symptom Fixing Shot are you interested in?

If you want more than one, just let our provider know the they arrive!

Sex:*

MaleFemale

Height:*

Ex: 5’5”

Weight (lbs):*

Ex: 150

Are you currently pregnant?*

YesNoN/A

If “YES”, are you breastfeeding?*

YesNoN/A

Are you trying to get pregnant?*

YesNoN/A

Do you have any of the following medical conditions:*

If you selected “Other”, please list your medical condition(s)/diagnosis here:

Do you have any allergies?*

If your allergy was not listed, please enter it here:

Are you taking any medications or supplements?*

Medication(s)Supplement(s)None

Please list medication/supplement name, dose, frequency, and the reason for taking it:

I hereby declare that I have voluntarily chosen to receive intravenous (IV) rehydration therapy provided by Vital Flow. I have been informed and understand the nature, purpose, and potential risks associated with this procedure. By signing this Informed Consent and Waiver of Liability, I acknowledge that I have read and understood the following:

1. Nature of Treatment:

I understand that the IV rehydration therapy involves the administration of fluids, electrolytes, vitamins, and minerals directly into my bloodstream through an intravenous line. The purpose of this treatment is to restore hydration, replenish essential nutrients, and provide relief from symptoms associated with dehydration.

2. Potential Risks:

I am aware that, although rare, there are potential risks and complications associated with IV therapy, including but not limited to:

a. Infection or inflammation at the site of insertion.
b. Bruising, hematoma, or swelling at the injection site.
c. Allergic reactions to the substances infused.
d. Inadvertent puncture of blood vessels or nerves.
e. Discomfort, pain, or numbness during the procedure.
f. Adverse reactions to the treatment, such as dizziness, lightheadedness, or nausea.

3. Confidentiality and Privacy:

I understand that the information gathered during the consultation and treatment will be kept confidential in accordance with the applicable privacy laws and regulations. Vital Flow will not disclose my personal information to any third party without my consent, except as required by law.

4. Professional Qualifications:

I acknowledge that the individuals providing the IV rehydration therapy are trained and qualified professionals. They possess the necessary skills to perform the treatment safely and effectively.

5. Waiver of Liability:

In consideration of receiving the IV rehydration therapy, I, on behalf of myself, my heirs, and assigns, release, discharge, and hold harmless Vital Flow, its employees, contractors, and agents from any and all liability, claims, demands, damages, or actions arising out of or related to the IV therapy, including any negligence or misconduct on the part of Vital Flow or its representatives for this appointment and all future appointments.

6. Emergency Situations:

I acknowledge that in the event of a medical emergency, Vital Flow staff will make reasonable efforts to contact emergency medical services and provide them with relevant information regarding my treatment.

7. Voluntary Consent:

I confirm that I am undergoing this treatment voluntarily and of my own free will. I have had the opportunity to ask questions and have received satisfactory answers regarding the IV therapy. I have read and understood the above information, and I hereby consent to receive IV rehydration therapy provided by Vital Flow. I acknowledge that I have the option to receive a copy of this Informed Consent and Waiver of Liability by asking Vital Flow staff.

8. Post treatment:

I confirm I will remove the Co-Adhesive Bandage/Coban within 30 minutes of application. I understand some redness, minor discomfort, small bruising and bleeding at the injection site may occur. I understand that this usually dissipates in a minimal amount of time and bruising is normal and to be expected.

9. Release of medical history:

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I have informed Vital Flow staff of my medical history and current medications. This includes over the counter medications and supplements. I am aware of possible side effects and contraindications

10. Final Statement:

I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I am 18 years of age and older, or consent was provided by Legal Guardian/POA holder. I consent to photography and the use of my likeness on social media by Vital Flow. I have been given the option to do nothing, and I am choosing to proceed with the prescribed therapy. Vital Flow does not take or bill insurance for services rendered, all treatments & sales are final, non-refundable, and payment in full is due at time of service.

I have read and fully understand and AGREE to the terms within the above consent.*

YesNo

Signature*

If you have any questions you can ask them here and a member from our team will reach out!

This service is currently for Arizona only

Please read the following: