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CLIENT INTAKE FORM AND WAIVER

Agreement Consent & Release of Liability

The undersigned (or “Patient”) agrees to the IV vitamin therapy administration by Infusion Fusion LTD (Infusion Fusion ) for the limited purpose of boosting athletic performance or reducing fatigue and shorten physical fitness recovery time from participating in the Event described below. Patient understands IV vitamin therapy affects patients in various ways and may not meet Patient’s desired results.  IV vitamin therapy is provided for pre or post-Event health optimization purposes only, do not in any way constitute a medical diagnosis, and that additional screening or procedures not provided by Infusion Fusion might be required in the event a medical diagnosis is desired. Patient acknowledges and agrees it is their sole responsibility to consult with the Patient’s personal health care provider with regard to his or her health concerns and to obtain any follow-up care determined by that health care provider to be appropriate. Further, Patient understands that this screening is not a complete physical exam, and is not a substitute therefore.  Patient further understands that the administration of IV vitamin therapy requires a prick to Patient’s skin and Patient may experience some pain.

The undersigned agrees that he or she have truthfully disclosed all of Patient's health related history and information requested.  Patient understands that Infusion Fusion will not provide Patient's medical health information to any physician or health care provider for any further review of any health condition that may be disclosed by Patient.

The undersigned, on behalf of him or herself and his or her legal representatives, heirs, successors and assigns, does hereby release and forever discharge Infusion Fusion LTD and its agents, employees, successors and assigns, from any and all claims, losses, costs, expenses, and damages of any kind involving or related to errors, omissions, or negligence in the performance, procedures and administration of the IV vitamin therapy. Without limiting the foregoing, the undersigned agrees that if any condition exists that is not detected by the pre-IV vitamin therapy screening, Infusion Fusion LTD and its agents, employees, successors and assigns, shall not be held liable.

I HAVE READ THIS AGREEMENT, CONSENT AND RELEASE OF LIABILITY, UNDERSTAND ITS TERMS, UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE MADE TO ME. FURTHER, I INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY OF INFUSION FUSION LTD AND ITS AGENTS, EMPLOYEES, SUCCESSORS AND ASSIGNS TO THE GREATEST EXTENT ALLOWED BY LAW.

Patient's Signature:


Date: December 13, 2018

Infusion Fusion LTD HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.
This HIPAA Notice of Privacy Practices (the "Notice") contains important information regarding your medical information Infusion Fusion LTD  is required by law to maintain the privacy of protected health information, to provide individuals with notice of its legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. You have the right to receive a paper copy of this Notice and may ask us to give you a copy of this Notice at any time.  If you have any questions about this Notice please contact the person listed at the bottom of this Notice. We may, however, change our privacy practices and the terms of this Notice in the future, and those changes may affect all health information maintained by us.  If our privacy practices change, we will prominently post our revised Notice on our web site.

HIPAA generally permits use and disclosure of your health information without your permission for purposes of health care treatment, payment activities and health care operations.  These uses and disclosures are more fully described below. Please note that this Notice does not list every use or disclosure, instead it gives examples of the most common uses and disclosures.

PERMITTED USES AND SHARING OF YOUR HEALTH INFORMATION:
Treatment:  We will use and share your health information to ensure you are provided medical treatment and services.  For example, we may share your health information with a doctor or hospital that is providing you health care.

Health Care Operations:  We will use and share your health information for our operations that are authorized by law.  For example, we may share your health information with an outside contractor to audit the compliance of our operations with regulations.

Legal Requirements:  We will share health information about you when required to do so by federal or state law.

To Avoid Harm: We may use or share your health information to prevent a serious threat to your health and safety or the health and safety of others such as in abuse, neglect, or domestic violence situations, or for law enforcement purposes.

Health Oversight Activities:  We may share your health information with a health oversight agency for activities authorized by law.  These activities may include, for example, audits, investigations, and inspections.

Lawsuits and Disputes: We may share your health information in response to a valid judicial or administrative order.

Marketing and Sale of Health Information:  We will not use or disclose your health information for marketing purposes, or sell your health information, without your written Authorization.

Business Associates:  We may disclose your medical information to our business associates.  We have contracted with entities (defined as "business associates" under HIPAA) to help us administer our services.  We will enter into contracts with these entities requiring them to only use and disclose your health information as we are permitted to do so under HIPAA.

Other uses and disclosures not described in this Notice will be made only with your written authorization.

YOUR HEALTH INFORMATION RIGHTS:
Right to See and Get a Copy of Your Health Information: You may see and get a copy of your health information and billing records by making a written request to Infusion Fusion LTD (Infusion Fusion). We can only provide those records that were created for or on behalf of Infusion Fusion.

Right to be Notified Following a Breach of Your Unsecured Health Information: 
Infusion Fusion is required by law to notify you following a breach of your unsecured health information.  This notice will describe the circumstances of what happened and the information that was inappropriately used or disclosed.  You may receive this notice in the mail, or if you have elected to receive communications from us by email, through an email sent to the email address that we have on file for you.

Right to Request that We Correct Your Health Information: If you feel that the health information we have provided to you is incorrect or incomplete, you may ask us to amend the information by making a written request to us.  In certain cases, we may deny your request to amend your information.

Right to a List of Disclosures Made of Your Health Information: You have the right to a list of those instances in which we have shared your health information, other than for treatment, payment, and health care operations, or other than when you specifically authorized us to share your information. Your request must be in writing to us.

Right to Request that Your Health Information be Communicated in a Confidential Manner: You may request that we contact you in a specific way, for example, home or office phone, or to send mail to a different address. We will consider all reasonable requests, and will agree to your request if you tell us you would be in danger if we did not.

Right to Request that We Not Use or Share Your Health Information: You have the right to request that we not use or share your health information for treatment, payment, or health care operations. This would include your right to request that we not share your information with persons involved in your care except when specifically authorized by you. Your request must be in writing to us, and we will consider your request but we are not legally required to agree to it.

FOR MORE INFORMATION OR TO REPORT A PROBLEM:
If you have questions about your privacy rights, would like additional information about something in this Notice, or would like to file a complaint because you believe your privacy rights have been violated, you may contact the person listed at the bottom of this Notice.

You may also file a complaint with the Secretary of the United States Department of Health and Human Services at:

Secretary/U.S. Department of Health and Human Services Office of Civil Rights; 200 Independence Avenue, SW Washington, DC  20201
Or by visiting:   http://www.hhs.gov/ocr/privacylhipaa/complaints/index.html

You will not be retaliated against for filing a complaint.

This Notice is effective as of Feb 18, 2018
Your written authorization is required for: most uses and disclosures of psychotherapy notes; uses and disclosures of PHI for marketing purposes; and disclosures that are a sale of PHI. You may revoke your authorization at any time, but you cannot revoke your authorization if we have already acted on it.

We understand that medical information about you and your health is personal and we are committed to protecting your medical information.

HIPAA Notice of Privacy Practices Acknowledgment Form
I acknowledge that I have received the HIPAA Notice of Privacy Practices (the "Notice") from Infusion Fusion LTD and that I have been provided an opportunity to review it. I understand that:

  • I have certain rights to privacy regarding my protected health information.
     
  • Infusion Fusion LTD can and will use my health information for purposes of my treatment, payment for treatment and health care operations.
     
  • The Notice explains in more detail how Infusion Fusion LTD  may use and share my protected health information for other purposes.
     
  • I have the rights regarding my protected health information listed in the Notice.
     
  • Infusion Fusion LTD has the right to change the Notice from time to time and I can obtain a current copy of the Notice by contacting the person listed in the Notice or viewing the current Notice on Infusion Fusion’s website.


Date: December 13, 2018

 

  1. Should a staff member receive 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).    Infusion Fusion LTD assumes all costs of further necessary testing.  Testing shall be performed within 24 hours of needle stick injury at nearby lab facility.
     
  2. Infusion Fusion reserves the right to refuse to initiate or continue iV treatment at any time based on paramedic, RN or staff discretion.


Date: December 13, 2018

This form has been approved for client intake by Dr. Jordan Brown.

First Participant's Name

First Name*

Middle Name

Last Name*

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

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
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*

Relationship*

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

All questions contained in this questionnaire are strictly confidential and will become part of your medical record with Infusion Fusion

PERSONAL HEALTH HISTORY

History of the following:
Diabetes
Cardiomyopathy
Prolonged QTc
Recent Fever or Illness
GI Bleeding
Stomach Ulcers
Congestive Heart Failure
Irregular Heart Rate
Renal (Kidney) Disease
HIV/Hepatitis
History of Syncope (Fainting)
In the last 12 hours, have you:
Eaten
Rest / Slept
Drank fluids
Urinated

List your prescribed drugs and over-the-counter medications, including vitamins, supplement or inhalers

Allergies (Type/Reaction):

Please describe any Medical Conditions, Medications and Allergies.
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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