Please list all medications you are currently taking.
I understand that by signing this agreement, I am authorizing Raider Rehab, LLC to provide IV hydration services. The known risks have been explained, and I am fully aware of the risks involved in this medical procedure. I’m also aware that there are risks accompanying any medical procedure and there is no guarantee of the results of the services, as well as, freedom from potential complications. I acknowledge and agree to be responsible, at the time of the service, for the full amount of any charges for the IV hydration services provided. I have read, understand, and have a copy of this consent and accept all terms listed above. This document is intended to serve as confirmation of informed consent for IV hydration therapy and related services as provided by Raider Rehab, LLC. I understand that participating in intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, and related services made available by Raider Rehab, LLC carries risks.
I expressly represent and warrant to Raider Rehab, LLC that I have never been diagnosed with nor treated for any diseases, illnesses, or conditions which may result in increased risk when I participate in services made available by Raider Rehab, LLC, and I am not choosing to participate with any expectations that Raider Rehab, LLC, will screen for, diagnose, monitor, or otherwise provide any care or treatment for such conditions. I expressly represent and warrant to Raider Rehab, LLC that I am not a user of illegal drugs and/or controlled substances and am not under the influence of the same or recovering from use of the same at the time of the provision of services. I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such regimen, programs and services rests entirely with me to the extent that I do not disclose my health conditions, medications or drug use in advance. I acknowledge and understand that Raider Rehab, LLC is relying upon the foregoing representations and warranties in providing IV hydration therapy and related services.
Possible risks include the following: injury, bleeding, infection, inflammation/swelling, bruising or scarring resulting from IV infiltration, extraction and extravasation. misplacement of IV lines in the body, air embolism, fluid overload, medication adverse interactions, nerve injuries, light headedness or fainting. I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the risks intended from the services offered by Raider Rehab, LLC. I understand the nature of the services and that participating carries risks. I have been given an opportunity to ask questions, and all of my questions have been entered fully into my satisfaction. I agree to my assumption of all risks associated with my participation in the services.
The patient has received and understood the informed consent provided herein and the risk associated with the services to be provided. Patient, in consideration of receiving the services provided by Raider Rehab, does hereby release and hold Raider Rehab, its successors and assigns, employees and owners, harmless from any claim of injury or damage whatsoever caused by the services provided. This hold harmless shall be construed in the broadest possible manner and shall include but not be limited to all claims, known or unknown of any character resulting from the services provided.