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IV Therapy and IM Injection

Informed Consent Liability Waiver

WAIVER OF LIABILITY AND RELEASE

  1. IN CONSIDERATION FOR UNDERGOING INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTION THERAPY, I, THE UNDERSIGNED, FOR MYSELF, MY HEIRS, ELECTORS, ADMINISTRATORS AND ASSIGNS, HEREBY RELEASE, WAIVE, DISCHARGE AND HOLD HARMLESS RELANY LLC, CRYOFIT AMERICAS, INC. AND THE RESPECTIVE EMPLOYEES, REPRESENTATIVES, DESIGNEES, MEMBERS, MANAGERS, AGENTS, OFFICERS, AND BOARDS OF RELEASEES, AND THE SUCCESSORS AND ASSIGNS OF ANY OF THEM, (HEREINAFTER JOINTLY REFERRED TO AS AGENTS), WITHOUT LIMITATION, FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, AND CAUSES OF ACTION WHATSOEVER ARISING OUT OF, RELATED TO OR CONNECTED IN ANY WAY WITH ME ENTERING THE CRYOFIT PREMISES, MY PARTICIPATION IN INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS, ANY OF WHICH MAY CAUSE DAMAGE OR INJURY TO ME WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEE AND ITS AGENTS OR CARELESSNESS OR OTHERWISE.
  2. MY PARTICIPATION IN INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS IS VOLUNTARY AND DONE AT MY OWN RISK. I HEREBY CONFIRM THAT NO WARRANTY, GUARANTEE OR OTHER ASSURANCE HAS BEEN MADE TO ME BY RELEASEE OR ITS AGENTS COVERING THE RESULTS OF THE INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS, WHICH HAS BEEN EXPLAINED TO ME. I UNDERSTAND THE ADMINISTRATION OF INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS, INCLUDING POSSIBLE ADVERSE REACTIONS, SIDE EFFECTS, OR OTHER POSSIBLE COMPLICATIONS FROM IT. I UNDERSTAND, CONSENT, AND AGREE TO ASSUME THOSE RISKS IN ADVANCE OF ANY INTRAVENOUS THERAPY, INTRAMUSCULAR INJECTIONS, OR FROM ME ENTERING THE BIOWORX by CRYOFIT PREMISES TO ENGAGE IN SUCH USAGE. 
  3. I AGREE TO INDEMNIFY, HOLD HARMLESS AND RELEASE THE RELEASEE AND ITS AGENTS, WHO THROUGH NEGLIGENCE OR CARELESSNESS OR OTHERWISE, MIGHT BE LIABLE TO ME (OR MY HEIRS, PERSONAL REPRESENTATIVES OR ASSIGNS) FOR DAMAGES THAT MAY OCCUR DUE TO MY PARTICIPATION IN INTRAVENOUS THERAPY, INTRAMUSCULAR INJECTIONS OR FROM ME ENTERING THE BIOWORX by CRYOFIT PREMISES TO ENGAGE IN SUCH USAGE.
  4. I AGREE THAT THIS WAIVER OF LIABILITY AND RELEASE SHALL BE CONSTRUED UNDER THE LAWS OF THE STATE OF WISCONSIN.
  5. I UNDERSTAND THAT INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS ARE USED ONLY BY PERSONS IN GOOD GENERAL HEALTH. I HAVE BEEN ADVISED THAT IF I SUFFER FROM ANY MEDICAL CONDITIONS OR ILLNESS WHATSOEVER, I SHOULD NOT RECEIVE INTRAVENOUS THERAPY OR INTRAMUSCULAR INJECTION.
  6. I UNDERSTANT RELANY, LLC HAS A RIGHT TO REFUSE ANY REFUNDS BEYOND 30 DAYS SINCE ROYALTIES AMONG OTHER EXPENSES ASSOCIATED WITH THE COST FOR SERVICE HAS BEEN DEDUCTED.

I ACKNOWLEDGE AND REPRESENT THAT (1) I HAVE READ, UNDERSTAND AND FULLY AGREE TO THE FOREGOING WAIVER OF LIABILITY AND RELEASE, (2) THE PROPOSED INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS HAVE BEEN SATISFACTORILY EXPLAINED TO ME AND I HAVE ALL OF THE INFORMATION I DESIRE, (3) I HAVE HAD A PREVIOUS MEDICAL EXAMINATION TO ASSURE MYSELF AND ASSUME MY OWN RESPONSIBILITY OF GOOD HEALTH AND CAPABILITY TO RECEIVE INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS, AND (4) I HEREBY GIVE MY AUTHORIZATION AND CONSENT. THIS WAIVER OF LIABILITY AND RELEASE IS EFFECTIVE AS LONG AS I UNDERGO INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS AT THIS LOCATION NOW AND IN THE FUTURE. NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENTS APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE BY RELEASEE OR ITS AGENTS; I AM AT LEAST 18 YEARS OLD AND FULLY COMPETENT; AND I AGREE THAT I WILL COMPLY WITH ALL INSTRUCTIONS REGARDING INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS. I AGREE TO AND UNDERSTAND THAT REFUNDS ARE NOT GIVEN ON INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS.


Informed Consent For Intravenous (IV) Therapy and Intramuscular (IM) Injections

This document is intended to serve as confirmation of informed consent for IV therapy and IM injections at BioworX by CryoFit. 

I, the undersigned, hereby authorize the physicians and nurses to administer IV therapy and/or IM injections. I understand that each physician independently contracts with Relany LLC, and is thus independently responsible for my medical care, and that Relany LLC and CryoFit Americas, Inc. do not hold any responsibility for medical decisions made or treatments provided. 

I understand the IV procedure involves inserting a needle into your vein and infusing prescribed nutrients (vitamins, minerals and amino acids) over a determined period of time. I realize that there may be some discomfort at the site of treatment and that it is my responsibility to inform the physician or nurse of any burning, pain or negative reactions I may experience. During IV treatment, it is possible for the injection fluid to leak out of the vein into the surrounding tissue. I understand that, although the infiltrated fluid may cause pain, it is not dangerous to my health and my body will absorb the fluid. I realize that, during and after my treatment, I may experience temporary discomfort at the site of treatment.

I will inform the physician of any known allergies to drugs or other substances that may be included in the ingredients of my solutions.


I will inform the physician of all current medications and supplements.


I understand that risks, benefits and alternatives to IVs and IM injections may include but are not limited to:

1. Risks and Potential Side Effects

  • Discomfort, bruising and pain at the site of injection.
  • Inflammation of the vein used for injection, phlebitis, metabolic disturbances and injury.
  • Severe reaction, anaphylaxis, cardiac arrest, or death.


2. Benefits

  • Injectables are not affected by stomach or intestinal disease.
  • Total amount of infusion enters the bloodstream and is available to the tissues.
  • Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth.


3. Alternatives to intravenous vitamin therapy include 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 PRIOR TO ITS PERFORMANCE. MY SIGNATURE ON THIS FORM AFFIRMS THAT I HAVE GIVEN MY CONSENT TO IV THERAPY AND IM INJECTIONS OR WITH ANY DIFFERENT OR FURTHER PROCEDURE, WHICH IN THE OPINION OF MY PHYSICIAN(S) OR OTHER(S) ASSOCIATED WITH THIS PRACTICE, MAY BE INDICATED.

I UNDERSTAND THE INFORMATION PROVIDED ON THIS FORM AND AGREE TO THE FOREGOING. I UNDERSTAND THAT THERE IS NO IMPLIED OR STATED GUARANTEE OF THE SUCCESS OR EFFECTIVENESS OF ANY TREATMENT. THE PROCEDURE(S) SET FORTH ABOVE HAS BEEN ADEQUATELY EXPLAINED TO ME BY MY PHYSICIAN.

Kindly note that packages have a one-year or 365-day expiration period from the date of purchase. By signing this form, you acknowledge and comply with this policy. After the expiration period, all packages will no longer be valid.



Ozone Therapy 

Ozone is a gaseous molecule consisting of pure oxygen that stimulates the body’s natural healing processes. 

Ozone Therapy is felt to have health-promoting effects, such as modulating immune function, improving energy, reducing pain, weakness, and supporting the immune system to fight against chronic and acute infections, and frailties of aging. 

We provide wellness and non-medical applications. We do not claim to treat, cure, or prevent disease or sickness. 

These therapies are considered medically unnecessary. They may not mitigate, alleviate, or treat any medical condition. These therapies have been recommended for their health-promoting benefits and their use is intended to support and improve the condition of your general overall health. 

The therapy that you will receive today employs the use of ozone. In this procedure, blood is withdrawn and mixed with an oxygen/ozone gas mixture. The blood is then returned to you. Ozone Intravenous therapy or any other mode of application recommended by your medical provider involves inserting an intravenous catheter and administering intravenous fluid into the vein, muscle, joint, etc. 

There is always some risk to any procedure, regardless of how rare. It is always possible to have allergic reactions to just about any medication, which, in a worst-case scenario, can cause a life-threatening reaction. There are occasional herxheimer reactions (infectious organisms which die off and cause symptoms of detoxification). These can include self-limiting, mild to moderate flu-like symptoms: fever, chills, pain, aching, headache, fatigue, lethargy, rashes, and phlegm. 


Although rare, there are some risks associated with intravenous therapy including: 

- Burning and stinging at the infusion site 

- Muscular spasms, weakness, or fatigue 

- Local Thrombophlebitis 

- IV infiltrates into surrounding tissue that can cause temporary burning or stinging. These therapies have not knowingly, been reported, to cause allergy related responses. 


Notice of Privacy Practices 

Your health information may be used by staff members or disclosed to other health care professionals for the purpose of reviewing your health, and providing therapies. Agents, and assigns do not evaluate health or diagnose medical conditions. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals and employees who may provide therapies or who may be consulted by staff members. Appointment reminders: Your information will be used by our staff to send you appointment reminders. You have the right to receive a printed copy of this notice. 

Please sign below to indicate you: 

I fully understand and accept the possible risk for the possible benefits of oxidation therapy. I agree to release and hold harmless all practitioners, consultants, associates and staff from any and all liability associated with the procedure(s) that I receive. I understand that I have sought treatment using ozone therapy and have not been forced to do this. 

Notice to Cancer Patients: We do not treat cancer. We treat the immune system to be able to respond better to cancer. All healing is done by restoration of the immune system to full function. When the patients’ own immune system is strong enough then it will take care of the cancer. 

It is my responsibility to keep my medical provider up to date with all of the current medications and supplements that I am taking, so that he/she can make the best-informed recommendations for my care. 


I do not expect the nurse and/or doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the nurse and/or doctor to exercise judgment in recommending the treatments that the nurse and/or doctor feels at the time, based on the facts then known, are in my best interest. I have had the opportunity to ask questions and discuss with clinicians at (YOUR BUSINESS NAME), and/or an allied health care provider to my satisfaction: 

1) my suspected diagnosis or condition 

2) the nature, purpose, and potential benefit of the proposed care 

3) the inherent risks, complications, potential hazards, or side effects of the treatment or procedure 

4) the probability or likelihood of success 

5) reasonable available alternatives to the proposed treatment / procedure 6) the possible consequences if treatment or advice is not followed and/or nothing is done. 


I further acknowledge that no guarantees or assurances have been made to me concerning the results intended for the treatment.

I assume full liability for any adverse effects that may result in the non-negligent administration of the proposed therapy. I waive the claim in law or equity for redress of any grievance that I may have concerning or resulting from the therapy, except that pertains to the negligent administration of this therapy. 

I also verify that all information presented regarding my medical history is true to the best of my knowledge and I am not misrepresenting my current health status or my medical history 

By signing this consent form I have agreed to the following: I have been informed of my rights, understand the therapy I am about to receive, and I authorize and consent to the therapies. 

I acknowledge that Ozone Therapy is NOT approved by the FDA and is considered experimental. 

  1. IN CONSIDERATION FOR UNDERGOING INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTION THERAPY, I, THE UNDERSIGNED, FOR MYSELF, MY HEIRS, ELECTORS, ADMINISTRATORS AND ASSIGNS, HEREBY RELEASE, WAIVE, DISCHARGE AND HOLD HARMLESS RELANY LLC, CRYOFIT AMERICAS, INC. AND THE RESPECTIVE EMPLOYEES, REPRESENTATIVES, DESIGNEES, MEMBERS, MANAGERS, AGENTS, OFFICERS, AND BOARDS OF RELEASEES, AND THE SUCCESSORS AND ASSIGNS OF ANY OF THEM, (HEREINAFTER JOINTLY REFERRED TO AS AGENTS), WITHOUT LIMITATION, FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, AND CAUSES OF ACTION WHATSOEVER ARISING OUT OF, RELATED TO OR CONNECTED IN ANY WAY WITH ME ENTERING THE CRYOFIT PREMISES, MY PARTICIPATION IN INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS, ANY OF WHICH MAY CAUSE DAMAGE OR INJURY TO ME WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEE AND ITS AGENTS OR CARELESSNESS OR OTHERWISE.
  2. MY PARTICIPATION IN INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS IS VOLUNTARY AND DONE AT MY OWN RISK. I HEREBY CONFIRM THAT NO WARRANTY, GUARANTEE OR OTHER ASSURANCE HAS BEEN MADE TO ME BY RELEASEE OR ITS AGENTS COVERING THE RESULTS OF THE INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS, WHICH HAS BEEN EXPLAINED TO ME. I UNDERSTAND THE ADMINISTRATION OF INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS, INCLUDING POSSIBLE ADVERSE REACTIONS, SIDE EFFECTS, OR OTHER POSSIBLE COMPLICATIONS FROM IT. I UNDERSTAND, CONSENT, AND AGREE TO ASSUME THOSE RISKS IN ADVANCE OF ANY INTRAVENOUS THERAPY, INTRAMUSCULAR INJECTIONS, OR FROM ME ENTERING THE CRYOFIT PREMISES TO ENGAGE IN SUCH USAGE. 
  3. I AGREE TO INDEMNIFY, HOLD HARMLESS AND RELEASE THE RELEASEE AND ITS AGENTS, WHO THROUGH NEGLIGENCE OR CARELESSNESS OR OTHERWISE, MIGHT BE LIABLE TO ME (OR MY HEIRS, PERSONAL REPRESENTATIVES OR ASSIGNS) FOR DAMAGES THAT MAY OCCUR DUE TO MY PARTICIPATION IN INTRAVENOUS THERAPY, INTRAMUSCULAR INJECTIONS OR FROM ME ENTERING THE CRYOFIT PREMISES TO ENGAGE IN SUCH USAGE.
  4. I AGREE THAT THIS WAIVER OF LIABILITY AND RELEASE SHALL BE CONSTRUED UNDER THE LAWS OF THE STATE OF WISCONSIN.
  5. I UNDERSTAND THAT INTRAVENOUS THERAPY AND INTRAMUSCULAR INJECTIONS ARE USED ONLY BY PERSONS IN GOOD GENERAL HEALTH. I HAVE BEEN ADVISED THAT IF I SUFFER FROM ANY MEDICAL CONDITIONS OR ILLNESS WHATSOEVER, I SHOULD NOT RECEIVE INTRAVENOUS THERAPY OR INTRAMUSCULAR INJECTION.
  6. I UNDERSTANT RELANY, LLC HAS A RIGHT TO REFUSE ANY REFUNDS BEYOND 30 DAYS SINCE ROYALTIES AMONG OTHER EXPENSES ASSOCIATED WITH THE COST FOR SERVICE HAS BEEN DEDUCTED.


If you are under 18 and receiving treatment, please have your guardian or parent print and sign. 

Kindly note that packages have a one-year or 365-day expiration period from the date of purchase. By signing this form, you acknowledge and comply with this policy. After the expiration period, all packages will no longer be valid.


Please select who will be participating...
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
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Email*

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Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
CLIENT MEDICAL HISTORY
Are you pregnant or do you think that you could be pregnant?*
No
Yes
Do you have a history of Congestive Heart Failure?*
No
Yes
Do you have a history of Heart Attack?*
No
Yes
Do you have a history of Strokes?*
No
Yes
Do you have a history of Irregular Heart Beat?*
No
Yes
Do you have a history of Kidney Disease?*
No
Yes
Do you have Stents?*
No
Yes
Do you have a Pacemaker?*
No
Yes
Do you have a history of Anemia?*
No
Yes
Do you have a history of Diabetes?*
No
Yes
Have you had cancer before or currently have cancer?*
No
Yes
Do you have a history of Seizures?*
No
Yes
Do you have a history of Breathing Problems?*
No
Yes
Do you have history of Headaches/Migraines?*
No
Yes
Are you currently taking blood thinners?*
No
Yes
Do you have a clotting disorder?*
No
Yes
Do you have a Latex allergy?*
No
Yes
Do you feel comfortable receiving your treatment in an open room environment?*
No
Yes
Do you feel healthy and well today?*
No
Yes
Drug Interactions

Current Medications

Current Supplements

Known Allergies
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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