Informed Consent DRIP IV Lounge, LLC & IV Success, PLLC Informed ConsentIV Hydration Therapy like any other medical treatment, has risks. There is no guarantee that IV hydration therapy will help achieve relief from hangover effects, athletic depletion, jet lag or illness; these symptoms vary greatly and individual results will vary. While many feel relief from hydration therapy, symptoms may return within the first 24 hours of treatment. Please drink in moderation. Excessive drinking after iv therapy can result in stomach irritation and other complications. Do not ever drink to excess with the assumption that iv hydration will be able to relieve your symptoms. Excessive drinking can lead to alcohol poisoning and other serious medical problems. Alcohol poisoning is a very serious, deadly condition. Always drink alcohol in moderation. I hereby grant permission to be treated for my symptoms, including, but not limited to: dehydration, headache, nausea, and vitamin deficiency. I understand that this treatment may involve an intravenous catheter (an "IV") and/or intramuscular injection and/or subcutaneous injection (each of the intramuscular and subcutaneous injections an "Injection"). I understand that medical treatment has risks. The most common risks of iv hydration therapy include, but are not limited to: allergic reaction to medications, vein irritation, heartburn, fluid overload, kidney problems, headache, and pain at the IV insertion or Injection site. The more rare side effects include, but are not limited to: inflammation of the vein used for injection, phlebitis, metabolic disturbance, and injury. The extremely rare side effects include, but are not limited to: severe allergic reaction, anaphylaxis, infection, and cardiac arrest. I have informed the nurse and/or other licensed medical profession (each, a "medical professional") of any known allergies to drugs or other substances or of any past reactions to anesthetics. I have informed the medical professional of all current medications and supplements.Initial*I am aware that other unforeseeable conditions could occur. I do not expect the medical professional(s) to anticipate and/or explain all risks and possible complications. I rely on the medical professional(s) to exercise judgment during the course of treatment. 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 procedure. My questions have all been answered in terms I understand. I am aware of the risks and potential side effects if I undergo hydration therapy. I have truthfully answered all questions regarding my medical history and have informed the staff about any and all prescription 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 drug use can lead to serious complications. I acknowledge that I am responsible for any medical care I have directly or indirectly related to my iv hydration therapy treatment. If there is an allergic reaction or otherwise, I agree that I am responsible for payment of my medical care. I represent and warrant that I understand the risks associated with hydration therapy. I hereby waive any and all claims and agree to hold DRIP IV Lounge, LLC and IV Success, PLLC harmless regarding any adverse reaction(s) I may have during or following the IV hydration treatment.Initial*My signature below confirms that: I am 18 years or older and am of sound legal mind to authorize and consent to the use of iv hydration therapy. The procedure set forth above has been adequately explained to me by my attending medical professional. I have received all the information and explanation I desire concerning the procedure. This document is intended to serve as confirmation of informed consent for iv hydration therapy.Patient*Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.