The undersigned (or “Patient/Client”) agrees to the IV vitamin therapy administration by Refresh Your Spirit Aesthetics LLC for the limited purpose of IV hydration, boosting athletic performance or reducing fatigue and shorten physical fitness recovery time as well as improve dehydration, headache, nausea, and vitamin deficiency. I understand that this treatment may involve an intravenous catheter (an IV and /or intramuscular injection and subcutaneous injections Patient understands IV vitamin therapy affects patients in various ways and may not meet Patient’s desired results.
Participating in vitamin therapy’s IV/IM there is no guarantee that it will help you achieve relief from your hangover effects, migraines, lack of energy, or illness. These symptoms vary greatly and individual results will vary. While many feel relief from hydration therapy, symptoms may return within the first 24 hours of treatment. Be aware excessive drinking after IV therapy can result in stomach irritation and other complications. Do not drink to excess with the assumption that IV hydration will be able to relieve your symptoms . Excessive drinking can lead to alcohol poisoning a very serious condition that can be deadly .
IV vitamin therapy is provided for health optimization purposes only, do not in any way constitute a medical diagnosis, and that additional screening or procedures not provided by Refresh Your Spirit Aesthetics LLC, 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 and follow-up care determined by that health care provider to be appropriate. Further, patient understands that the administration of IV vitamin therapy requires a prick to patient’s skin and patient may experience some pain.
I understand that medical treatment has risks. The most common risks from IV hydration therapy include, but are not limited to: allergic reaction as well as allergic reaction to medications, vein irritation,rash, heartburn, fluid overload, kidney problems, headache, pain at the IV insertion or injection site, bruising. The more rare side effects include, but are not limited to: inflammation of the vein,used for injection,plepbitis, metabolic disturbances and injury. The extremely rare side effects include, but are not limited to: severe allergic reaction, anaphylaxis, infection, cardiac arrest. I have informed the nurse and or other licensed medical professional of any known allergies to drugs or other substances or of any past reactions. I have informed the medical professional of all current medications and supplements and medical conditions.
The undersigned agrees that he or she have truthfully disclosed all of patient’s health related history and information requested. Patient understands that Refresh Your Spirit Aesthetics LLC 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 discloses by patient.
I undersigned, on behalf of him or herself and his or her legal representation, heirs, successors and assigns, does hereby release and forever discharge Refresh Your Spirit Aesthetics LLC 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 and further fully acknowledge and accept the risk of exposure to COVID-19 by participating in this services, that the virus may be present in any public area. Refresh Your Spirit Aesthetics LLC takes ever precaution, following Federal and Iowa state regulations and guidelines in regard to the current COVID-19 pandemic. Without limiting the foregoing, the undersigned agrees that if any condition exists that is not detected by the pre-IV vitamin therapy screening, Refresh Your Spirit Aesthetics LLC and its agents, employees, successors, and assigns, shall not be held liable. Anyone participating in this service.
1.Should a staff member receive a needle stick injury with potential for the 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.). Refresh Your Spirt Aesthetics LLC assumes all costs of further necessary testing. Testing shall be performed within 24 hours of needle stick injury at nearby lab facility.
2.Refresh Your Spirit Aesthetics LLC reserves the right to refuse to initiate or continue IV treatment at any time based on paramedic, RN or staff discretion.
YOUR HEALTH INFORMATION RIGHTS:
1.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 Refresh Your Spirit Aesthetics.
2.Right to be Notified Following a Breach of Your Unsecured Health Information: Refresh Your Spirit Esthetics 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, of 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.
3.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.
4.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.
5.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.
6.Right to Request that We Not Use of Share Your Health Information: You have the right 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 no 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.
Refresh Your Spirit Aesthetics LLC, HIPPA 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 Refresh Your Spirit Aesthetics is required by law to maintain the privacy of protect 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 5o receive a paper copy of this Notice may ask us to give you a copy of this Notice at any time. We may, however, change our privacy practices and 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 website.
HIPPA 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 disclosure are not fully described below. Please note that this Notice does not list every use of disclosure. Inste4ad it gives examples of the most common uses and disclosure.
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 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 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 healthy 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 so under HIPAA.
Other uses and disclosures not described in this Notice will be made only with your written authorization.
Date: September 28, 2022
I hereby acknowledge that I have been advised that photographs will be taken of me or parts of my body before and after procedures. I hereby give mu concent for Refresh Your Spirit Aesthetics to use my photo for one of the following: Internet, Print, & Broadcast Media: Photographs taken of me or parts of my body as well as details reguarding medical services that I have received at Refresh Your Spirit Aesthetics can be used on the company's website and social media platforms in order to inform the public about Aesthetic Medicine methods.Futher, I release and discharge, any employee of Refresh Your Spirit Aesthetics and all parties acting under their license and authority, from any and all claims or actions that I have or may have relating to such use and publication and all rights, if any, that I may have in such photographs and details regarding medical services rendered to me, including any claim for payment, in connection with any such use or publication. I give my consent as a voluntary contribution in the interest of public education,and my consent is subject only to the condition that I am not identified by name or any other identifying marks at any time during any use or publication of these materials by any party.
****Only initial if you want for medical use only:***** Medical only: Photographs taken of me or parts of my body can be used solely for the purpose of my medical care. The photographs and all details regarding medical services rendered to me will be kept confidential with in my personal medical history file at Refresh Your Spirit Aesthetics.