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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 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.

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 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 SUCCESS OR EFFECTIVENESS OF ANY TREATMENT.  THE PROCEDURE(S) SET FORTH ABOVE HAS BEEN ADEQUATELY EXPLAINED TO ME BY MY PHYSICIAN.

Date: June 18, 2021

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CLIENT MEDICAL HISTORY
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Do you have a history of Congestive Heart Failure?*
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Yes
Do you have a history of Heart Attack?*
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Yes
Do you have a history of Strokes?*
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Yes
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Do you feel healthy and well today?*
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Yes
Drug Interactions

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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.
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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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