This document is intended to serve as confirmation of informed consent for IV therapy as ordered by REVIVE HYDRATION.  I have informed the provider of any known allergies to drugs, supplements, or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics. In doing so, I understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with me insofar as to the extent to which I do not disclose those allergies in advance.

 

I have informed the provider of all current medications and supplements. In doing so, I understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with me in so far as to the extent to which I do not disclose my health conditions, medications, or supplements in advance.

 

I have informed the provider of all medical conditions, diseases, and illnesses. I attest that I have never been diagnosed with or treated for any such conditions that would put me at increased risk while receiving IV therapy services by REVIVE HYDRATION. I understand that I will be screened for said conditions prior to initiation of services.

 

I understand that I have the right to be informed of the risks and benefits before therapy administration. No procedures will be performed until I have had an opportunity to receive such information and to give my informed consent. REVIVE HYDRATION therapies are not intended for emergency care. 

 

The intravenous (IV) procedure involves inserting a needle into your vein and infusing the prescribed nutrients and/or medications over a determined period of time. That time will vary depending on your anatomy and infusion rate; however, the therapy should be expected to take about 30 to 60 minutes.

I understand that IV therapy carries with it both risks and benefits. Some of those risks and benefits include, but are not limited to:

 

The Risks and potential side effects

1. Discomfort, soreness, bleeding, bruising, pain and possible scarring at the site of injection.

2. Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

3. Lightheadedness or fainting.

4. Severe reaction to medication, supplement, or vitamin therapy; anaphylaxis, cardiac arrest or death.

5. Volume overload.

6. Air embolism.

7. Infiltration

 

The Benefits

1. Injectables are not affected by stomach or intestinal disease.

2. Total amount of infusion enters the bloodstream and is available to the tissues.

3. Higher doses of nutrients can be given by vein than by mouth,

4. Can be used in conjunction with oral supplementation and/or dietary and lifestyle changes.

 

I am aware that other unforeseeable complications could occur. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time before or during its performance. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedure/medications, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.

 

Lastly, I attest that I am not under the influence of illegal drugs or substances at the time of therapy. I agree that I am not using said therapy to recover from any drug related symptoms. I understand that if any suspicion of such is made by the provider, my right to therapy administration will be waived and will not be subject to a refund.

 

I understand that a record of my treatment will be generated with each visit. We are committed to your privacy and all health care information provided to REVIVE HYDRATION will be protected. Any disclosures of PHI (protected health information) will therefore require authorization, unless used in the following ways:

1. Quality improvement regarding REVIVE HYDRATION

2. Health related benefits and services referral

3. Any court ordered requests or subpoenas

4. Any law or government mandates with appropriate warrant

 

I understand the information provided on this form and agree to all therein. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. I understand that I am free to withdraw my consent and discontinue participation in their treatments at any time.

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Photo/Video Release -  I hereby authorize Revive Hydration LLC to edit, change, copy, and make any use of all photographs/videos of me/my event to be used for promotional materials.  I authorize the use of my photograph/video for, but not limited to, publication on the internet, magazines, journals, books, articles, etc., provided that it is done for lawful purposes. I hereby acknowledge that I will not be entitled to payment or any sort of charge for such action.

 

I understand that, except in emergencies, I must give 24-hour notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount of supply used due to wasted materials.