There is no guarantee that IV therapy treatment will temporarily or permanently cure or resolve your current condition, including dehydration, headache, hangover, the effects of altitude sickness, viral illness and/or jet lag. The symptoms of each of these conditions vary greatly and individual results will vary. Even if initially effective, some symptoms may return several hours after treatment.
I hereby grant QuickFix permission to provide IV therapy for the symptoms of that diagnosis, 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 this is a form of medical treatment and any such treatment involves risks. The most common risks from IV therapy include, but are not limited to:
- Allergic reaction to medications
- Vein irritation
- Fluid overload
- Pain or bruising at the IV insertion or injection site.
The more rare side effects include, but are not limited to: inflammation and/or infection of the vein used for injection, heartburn and metabolic disturbances and injury. Extremely rare side effects include, but are not limited to: severe allergic reaction, worsening infection, and cardiac arrest.
I have informed the nurse and/or other licensed medical professional of my recent activities, any known allergies to drugs or other substances or of any past reactions, and of all my current medications and supplements.
I am aware that other unforeseeable conditions could occur. I acknowledge that the medical professional has discussed with me the nature and purpose of the treatment and the risks, complications and consequences associated with the procedure. I acknowledge that I have been given the opportunity to ask questions and that my questions have all been answered in terms I understand. I am aware of the risks and potential side effects of IV therapy.
I have truthfully answered all questions regarding my medical history and have informed the medical professional about any and all prescription and/or over-the-counter drugs I take, as well as any recreational drugs. I understand that failing to inform the medical professional about my medical issues and drug use can lead to serious complications.
Choice of Law and Agreement to Arbitrate. This agreement is to be governed in all respects by the substantive laws of the State of New York, excluding any choice of law rules that might require that a law other than that of the State of New York apply. It is understood that any claim or controversy, whether in tort, contract or otherwise, arising from or relating to this agreement or the treatment or services provided by QuickFix, including without limitation any claim that medical services were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by arbitration pursuant to the American Arbitration Association Consumer Arbitration Rules before a single arbitrator in New York. The decision of the arbitrator shall be final and binding on all parties and the arbitration award may be enforced in any court of law in the United States having jurisdiction. Both parties to this contract, evidenced by patient's signature below QuickFix's acceptance of such signature, as 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.
Dated: May 21, 2019