Terms and Conditions

IV THERAPY INFORMED CONSENT FORM

This document is intended to serve as confirmation of informed consent for intravenous (IV) therapy as ordered by Drip River IV LLC (DRIV).  

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 IV 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 IV 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.  

I understand that I have the right to be informed of the risks and benefits before therapy procedure, and any alternative options. No procedures will be performed until I have had an opportunity to receive this information and to give my informed consent. DRIV therapies are not intended for emergency care. I understand that IV therapy is not standard, widely approved or accepted for the purpose(s) of treatment or prevention of disease and that IV therapy is considered an alternative treatment. 

I acknowledge that the IV procedure involves inserting a needle into the vein and injecting the prescribed nutrients and/or medications over a determined period of time. That time will vary depending on your anatomy and infusion rate, but should be expected to take about 30 to 60 minutes. 

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

Risks:
1. Occasionally: Discomfort, soreness, bleeding, bruising, pain at the site of injection.
2. Rare: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, injury, lightheadedness or fainting.
4. Extremely rare: Severe reaction to medication, supplement or vitamin therapy; anaphylaxis, cardiac arrest or death, volume overload, air embolism, infiltration.

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 that benefits of IV therapy may be limited if I am an active smoker, live a sedentary lifestyle, and/or have an unhealthy or excessive diet. I do not expect provider to anticipate or explain all possible complications from IV therapy. 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 submission of 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. 

I confirm 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 may be generated with each visit. DRIV is committed to your privacy and all health care information provided to DRIV will be protected. DRIV will not disclose any HIPAA protected information, unless used in the following ways: 

1. Requested by you.
2. Any court ordered requests or subpoena.
3. 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. 

I understand that, except in emergencies, I must give 24 hours’ 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. 

I understand I should inform my primary care provider of all services I receive from DRIV.

While I understand that there have been no warranties or guarantees of successful treatment made to me, I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations and materials that may be provided to me by DRIV to educate me about the treatment. Individual results may vary.  

I, in signing and consenting below, understand and acknowledge that the United States Food and Drug Administration has not evaluated or approved the treatments I am about to receive to diagnose, treat, cure, or prevent any disease.

WAIVER OF LIABILITY 

For and in consideration of good and valuable consideration, including, but not limited to, the following instruction and certification(s), the receipt and sufficiency of which is acknowledged hereby, I hereby waive my rights to all claims for injuries, risks, adverse effects, and life-threatening medical and clinical conditions, be they physical, fiscal or otherwise, that I may sustain arising out of IV therapy or any subsequent activities arising therefrom. I acknowledge that participation in IV therapy is voluntary. I hereby fully release and discharge DRIV and its officers, agents and employees from any and all claims from injuries, including death damage or loss, which I may have as a result of this service and the therapies provided by DRIV. I agree to indemnify and hold DRIV harmless from and against any and all damages, costs, claims or demands, including reasonable attorneys’ fees, made by any third party due to or arising from or relating to my use of DRIV services. 

My acceptance of this form, including the informed consent and waiver of liability, confirms that:
1. I understand the information provided on this form and consent to treatment.
2. The procedure(s) set forth above has been adequately explained.
3. I have received all the information and explanation I desire pertaining to the procedure.
4. I authorize and consent to the procedure(s).