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City Hydration LLC. Informed Consent and Arbitration Agreement

 

IV Hydration Therapy like any other medical treatment, has risks.

There is no guarentee 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, syptoms may return within the first 24 hours of treatment.

Please drink alcohol 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 from 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 disturbances 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.

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 City Hydration, LLC ("City Hydration") harmless regarding any adverse reaction(s) I may have during or following the iv hydration therapy treatment.

 

Agreement to Arbitrate. It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Pennsylvania law and not by a lawsuit or resort to court process of any form, except as Pennsylvania law provides for judicial review of arbitration proceedings. Both parties to this contract, evidenced by patient’s signature below and City Hydration's acceptance of such signature, are voluntarily waiving their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration.

All Claims Must be Arbitrated. It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies, whether lying in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by any physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers affiliated with City Hydration (collectively herein referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Physician of any action in any court by the Physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Procedures and Applicable Law. A notice or demand for arbitration must be communicated in writing by U .S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his or her attorney. The parties shall thereafter select a mutually agreeable arbitrator to preside over the matter. The parties shall bear their own costs, fees and expenses, along with a pro rata share of the arbitrator’s fees and expenses.

Severability Provision. In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of this agreement enforced in accordance with Pennsylvania and federal law.

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.

Dated: December 16, 2018

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

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Height *

Weight (lbs) *

Allergies

Medications (including herbal and supplements)
Medical History
kidney disease/renal insufficiency
heart failure
gi bleed
blood thinners
steroids
liver disease
other

*****If you have any of the above medical conditions you may not be medically cleared for IV therapy. Please discuss this with your nurse before continuing further. 

Do you have any medical concerns at this point?*

If yes, please describe
Could you be pregnant?*
Are you breast feeding?*

What services are you interested in receiving today? *

How did you hear about us?

Questions/comments/concerns?

1. Should a staff member have a needle stick injury with potential for blood-to-blood transmission with client, client agrees to obtain formal blood testing to rule out potential of communicable disease transmission via OSHA standards (HIV, Hepatitis, etc).  City Hydration assumes all costs of further necessary testing.  Testing shall be performed within 24 hours of needle stick injury at nearby lab facility.

2. City Hydration reserves the right to refuse to initiate or continue iV treatment at any time based on RN or staff discretion.

First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

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

Emergency Contact's Name*

Emergency Contact's Phone Number*
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Height *

Weight (lbs) *

Allergies

Medications (including herbal and supplements)
Medical History
kidney disease/renal insufficiency
heart failure
gi bleed
blood thinners
steroids
liver disease
other

*****If you have any of the above medical conditions you may not be medically cleared for IV therapy. Please discuss this with your nurse before continuing further. 

Do you have any medical concerns at this point?*

If yes, please describe
Could you be pregnant?*
Are you breast feeding?*

What services are you interested in receiving today? *

How did you hear about us?

Questions/comments/concerns?

1. Should a staff member have a needle stick injury with potential for blood-to-blood transmission with client, client agrees to obtain formal blood testing to rule out potential of communicable disease transmission via OSHA standards (HIV, Hepatitis, etc).  City Hydration assumes all costs of further necessary testing.  Testing shall be performed within 24 hours of needle stick injury at nearby lab facility.

2. City Hydration reserves the right to refuse to initiate or continue iV treatment at any time based on RN or staff discretion.

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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