Loading...

Quick Fix Therapy
Informed Consent and Arbitration Agreement

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: November 16, 2019

First Patient's Name

First Name*

Last Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
First Patient's Signature*
Second Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Third Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Fourth Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Fifth Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Sixth Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Seventh Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Eighth Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Ninth Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Tenth Patient's Name

First Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Patient'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*
Emergency Contact

Name *

Relationship *

Phone *
Consent for utilization of Photos or Video
I agree to let QuickFix utilize photos or video obtained for promotional marketing.*
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*

Last Name*

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

I understand that I have received the following diagnosis: *

Height *

Weight *

Current Medications (including prescriptions, supplements, and over the counter)


Medication / Dosage
Have you used any illegal drugs within the last 24 hours?*
No
Yes

List:

Allergies:


Allergy / Reaction
Medical History: Check if you have a history of any of the following
Hypertension
Kidney Disease
Liver disease
Heart Failure
Stomach ulcer or GERD

What service are you interested in today?
Please select a number that matches how you currently feel*
Is there any chance that you may be pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver