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Informed Consent & Release of Liability Agreement

 

By signing here I, the signee herby authorize ReVITALize IV Hydration Therapy, PLLC to administer IV treatment on me. I have reviewed the purpose of this treatment, have received descriptions of the additives and have been offered the opportunity to ask any/all questions. I have received an explanation of how the treatment will be administered as well as any side effects that may arise that are included but not limited to infiltration of IV, phlebitis of vein, infection, allergic reactions, irritation, swelling and pain at insertion site. I am aware that these side effects may arise even when treatment is administered properly and I am agreeing to not hold ReVITALize IV Hydration Therapy, PLLC responsible.

If you provide us with verbal permission, we may use photos, videos, testimonials or company reviews of you on our social media accounts or websites for promotional purposes. You may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization; however, we will be unable to take back any disclosures already made based upon your original permission.

 

I understand that healthcare professionals involved in my care will rely on my documented medical history provided and I am aware if I have any concerns about how this treatment will affect me that I have the option to first consult with my primary care provider. I agree to provide accurate information regarding my medical history, conditions and current medications I am taking. I understand that ReVITALize IV Hydration Therapy, PLLC procedures are only designed to treat symptoms associated with mild dehydration and no labs, x-rays or other detailed diagnostic services will be provided before treatment. ReVITALize IV Hydration Therapy, PLLC reserves the right to refuse treatment if risks outweigh benefits based on our basic medical exam and healthy history obtained from you.

The services provided have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. Recommended drip packages are solely recommendations and do not serve as medical advice. Always consult with your provider before beginning any treatment or therapy program. Any designations or references to therapies are for marketing purposes only and do not represent actual products.

I understand the risks of this treatment and that in extremely serious circumstances, could result in permanent injury or even death. In the event that these circumstances occur, I understand that the cost of treatment and hospitalization will not be the responsibility of ReVITALize IV Hydration Therapy, PLLC.

ReVITALize IV Hydration Therapy, PLLC and its representatives cannot guarantee results from any treatment. A lot of these treatments take multiple sessions before you start feeling results. I release ReVITALize IV Hydration Therapy, PLLC from any liability, accident or injury that is not directly caused by negligence of ReVITALize IV Therapy, PLLC or it’s representatives.

 

 

I acknowledge that I am legally responsible for all charges in connection with the medical care and treatment provided by healthcare professionals of ReVITALize IV Hydration Therapy, PLLC.

 

 

By signing this document, I certify that I have read and understand its contents and that information by me is accurate and complete. I hereby authorize ReVITALize IV Hydration Therapy, PLLC to service me and this waiver will remain active for as long as I receive care from the business or until I withdrawal my consent in writing. A copy of this document will be sent to you as long as you request it from ReVITALize IV Hydration Therapy, PLLC or it’s representatives. A copy of this document may be utilized and it will serve and hold the same standards as the original.

 

 

 

Signature:

September 17, 2024

 

 

ReVITALize IV Hydration Therapy, PLLC

Notice of Privacy Practices

 

 

This notice explains that medical information about you may be used and disclosed and how you can get access to this information.

ReVITALize IV Hydration Therapy, PLLC will gather certain health and medication information about you and will create a record of the care provided to you. Other individuals or organizations that are part of your “circle of care” such as the referring physician, your other healthcare providers, your other healthcare providers, your health plan, and close friends or family members- may also share information with us. We may also use or share your health information with other parties for a variety of important purposes, including some purpose described below.

ReVITALize IV Hydration Therapy, PLLC is committed to protecting the privacy and confidentiality of your health information. In keeping with this commitment, this Notice describes the privacy practices of our physicians, employees and other staff members. Federal law requires that we: (I) maintain the privacy of medical information provided to us (ii) provide this Notice of our legal duties and privacy practices to you; and (iii) abide by the terms of this notice currently in effect.

We reserve the right to make changes to this notice at any time, and to make such changes effective for personal health information we have about you as well as any information we receive in the future. In the event there is a material change to this Notice, the revised Notice will be posted and made available to you upon request.

 

 

HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU

 

 

We may use and disclose personal and identifiable health information about you in different ways.

All of the ways in which we may use and disclose information without your prior permission will fall within one of the following listed categories, although not every possible use or disclosure falling within a category will be listed. We are required to obtain your written authorization for any other uses and disclosures of your health information not listed below. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization; however, we will be unable to take back any disclosures already made based upon your original permission.

 

1. Treatment. We will use health information about you to furnish healthcare services and supplies to you, in accordance with our policies and procedures. We may also communicate with other healthcare providers to coordinate or manage your healthcare. For example, we will use your medical history, such as any presence or absence of heart disease, to assess your health and perform requested services. As another example, we may use your health information to restock vitamin prescriptions provided at the time of treatment.

2. Treatment Alternatives. We may use and disclose your personal health information in order to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you.

3. Individuals Involved in Your Care or Payment for Your Care/Disaster Relief. We may disclose health information about you (i) to a relative, close personal friend, or any other person you identify as part of your “circle of care,” if the information is directly relevant to their involvement in your care; or (ii) to the above individuals or a disaster relief organization (such as the Red Cross), if we need to notify someone about your location or condition. You may object to any of these disclosures, and if you object, we will not disclose the information except in certain circumstances such as an emergency.

4. Waiting Rooms – We may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to begin your treatment.

5. Payment. We will use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. For example, we may need to give payer information about your current medical condition so that we may receive payment for the examinations or other services that we have furnished you.

6. Health Care Operations. We will use and disclose your health information to conduct the business activities of our organization. These activities include, but are not limited to, quality assessment and improvement activities, review of the performance and qualifications of employees, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

7. Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment or that you should schedule an appointment.

8. Business Associates. We sometimes work with outside individuals and businesses that help us operate our business successfully. We may disclose your health information to these business associates so that they can perform the tasks that we hire them to do. Our business associates must provide us with certain written assurances that they will respect the confidentiality of your personal and identifiable health information.

9. Required by Law. We may disclose health information about you when we are required to do so by federal, state, or local law, subject to the limitations of such law and the physician- patient privilege, as applicable.

10. Public Health. We may disclose protected health information (PHI) about you in connection with certain public health reporting activities. For instance, we may disclose such information to a public health authority authorized to collect or receive PHI for the purpose of preventing or controlling disease, injury or disability, or, at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority. Public health authorities include state health departments, the Center for Disease Control, the Food and Drug Administration, the Occupational Safety and Health Administration and the Environmental Protection Agency, to name a few. We are also permitted to disclose protected health information to a public health authority or other government authority authorized by law to receive reports of child abuse or neglect. Additionally, we may disclose protected health information to a person subject to the Food and Drug Administration’s power for the following activities: to report adverse events, product defects or problems, or biological product deviations, to track products, to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.

11. Abuse Neglect or Domestic Violence. We may disclose your protected health information in situations of domestic abuse or neglect or abuse of persons other than children.

12. Healthcare Oversight. We may disclose protected health information in connection with certain health oversight activities of licensing and other agencies. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of 1) the health care system, 2) governmental benefit programs for which health information is relevant to determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which health information is necessary for determining compliance with program standards, or 4) entities subject to civil rights laws for which health information is necessary for determining compliance.

13. Law Enforcement. We may disclose certain information in response to a warrant, subpoena, or other order of a court or administrative hearing body, and in connection with certain government investigations and law enforcement activities.

14. Decedents Information. We may release personal health information to a coroner or medical examiner to identify a deceased person or determine the cause of death, or to funeral directors. We also may release personal health information to organ procurement organizations, transplant centers, and eye or tissue banks.

15. Workers Compensation. We may release certain personal health information to workers’ compensation or similar programs.

16. Serious Threats to Health or Safety. Information about you also will be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of others.

17. Research. We may use or disclose certain personal health information about your condition and treatment for research purposes where an Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. We may also use and disclose your protected health information to prepare or analyze a research protocol and for other research purposes.

18. Armed Forces and other Government Functions. If you are a member of the Armed Forces, we may release personal health information about you as required by military command authorities. We also may release personal health information about foreign military personnel to the appropriate foreign military authority. We may also disclose protected health information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.

19. Judicial or Administrative Proceedings. We may disclose your protected health information for legal or administrative proceedings that involve you. We may release such information upon order of a court or administrative tribunal. We may also release protected health information in the absence of such an order and in response to a subpoena, discovery request or other lawful request, if certain steps have been taken to notify you or secure a protective order.

20. Inmates. If you are an inmate, we may under certain circumstances disclose protected health information about you to a correctional institution where you are incarcerated or to certain law enforcement officials.

 

 

 

OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

 

 

Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. Any use or disclosure of psychotherapy notes, uses and disclosures of PHI for marketing purposes and disclosures that constitute the sale of PHI require your written authorization. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing by contacting us at the address below. If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures which were being processed before we received your cancellation.

INDIVIDUAL RIGHTS

 

1. You have the right to ask for restrictions on the ways in which we use and disclose your medical information beyond those imposed by law. We will consider your request, but we are not required to agree to it. However, we do have to agree if you request that we not disclose your PHI to your health plan for health services or items for which you paid out-of-pocket in full. You may request a restriction by sending your request in writing to our Privacy Officer.

2. You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. We will try to accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing by contacting our Privacy Officer.

3. Except under certain circumstances, you have the right to access, inspect and copy medical and billing records about you. A reasonable cost-based fee will be charged for expenses such as staff time, copying, and mailing. Contact us as indicated at the end of this Notice to obtain information about our fees or if you have any questions about accessing your health information. All requests must be sent in writing to the Privacy Officer.

4. If you believe that certain information in your records is incorrect or incomplete, you have the right to ask us to correct or supplement the records. Under certain circumstances, we may deny your request.

5. You have a right to ask for a list of certain instances when we have used or disclosed your medical information. If you ask for this information from us more than once every twelve months, we will charge you a reasonable cost-based fee for each request.

6. You have the right to be notified in the event that we discover a breach of unsecured PHI involving your medical information.

COMMENTS/COMPLAINTS

 

If you have any questions, concerns or want to obtain more information concerning this Notice of Privacy Practices or if you are concerned that we may have violated your privacy rights or you disagree with a decision we have made regarding your access to your health information or any other request you have made in the exercise of your rights, you may you may contact us via email at revitalizehydration@gmail.com

CANCELATION POLICY

If you cancel your appointment 24 hours prior to start time, you can reschedule an appointment and transfer your $50 deposit to your next service IF that appointment is booked in the same month. If you do not rebook an appointment within that same month, you will have to re-pay a $50 deposit for your next appointment.

If you cancel more than 12 hours prior to treatment, you will not receive your $50 deposit back, but will not be charged the full price for your service.

If you cancel less than 12 hours prior to treatment, you will not receive a refund of your $50 deposit and will be charged for the full price of your service.

 

 

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Age
Please list any/all allergies

If you have no known allergies, please type "None" *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Home Address
City
State
Emergency Contact Name
Emergency Contact Relationship To You
Emergency Contact Phone Number
Do You Have Any of the following Health Conditions?
Please select all that apply. If you do not have any conditions, please select the last option for "No health conditions or medical history" *
Taking 2 or more blood pressure medications
Diabetes
Kidney disease/Kidney failure/Dialysis patient
Liver Failure
HIV/AIDS
Bleeding or Clotting Disorder
Heart Failure or History of heart disease
Stroke
Taking anticoagulants or "blood thinners"
Taking diuretics or "fluid pills"
No Medical Conditions
Other conditions not listed
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 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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