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IV Drip Therapy Intake Form & Release Agreement

General Statement

Welcome to Cambiati Wellness & Dr. Solt MD! We are so excited that you are starting your journey to health with us. We strive to assist our clients in achieving better health by suggesting foods, vitamins, herbs, appropriate testing, exercise, and lifestyle modification programs. We do not diagnose or treat disease. Always consult your physician before starting any fitness, diet, nutrition, or IV vitamin regimen.

We  have Registered Dietitian(s) and Certified Nutritionist(s) on staff but unless otherwise noted, our instructors, staff and volunteers are not nutritionists or registered dieticians, personal trainers, or physicians. We may help coordinate services for Dr. Solt MD through Cambiati Wellness but Cambiati Wellness is the manager of said services and Dr. Solt MD is not employed by Cambiati Wellness.

Acknowledgment of Risk and Informed Consent

I, the undersigned Client, certify that I am 18 years old or older and in good health. I hereby consent to voluntarily participating in the IV drip therapy, phlebotomy, nutrition, testing, exercise and wellness program offered by Cambiati Wellness Programs (collectively the Program) and to use Cambiati Wellness Programs facilities and premises (if applicable) in accordance with Cambiati Wellness Programs rules and policies. I certify that I have full knowledge of the nature and extent of the risks inherent in any IV drip therapy, nutrition, diet and exercise program, including injury (such as musculoskeletal strains or heart attacks), illness or death, and that I am voluntarily assuming these risks.

I understand that information provided by Cambiati Wellness Programs, Cambiati Wellness, and Dr. Solt MD including its instructors, staff, agents or volunteers, regarding nutrition, exercise, lifestyle and health are NOT meant to replace medical care or treatment for any health problem or condition. I understand that any recommendation for changes in diet including the use of nutrition supplements, weight reduction and/or muscle building products is entirely my responsibility and that I should consult a physician prior to undergoing any exercise, dietary or supplement regiment or changes. I also understand that I should check with my physician regarding any contra-indications among dietary changes, exercise, supplements and medications.

I further certify that I am responsible for how any medical condition(s) I may have may be affected by the Program, including any IV drip therapy, nutrition, exercise, or supplement recommendations. I understand that I should check with my physician before following any suggestions. If at any time during an exercise session I feel pain or discomfort I MUST STOP IMMEDIATELY and inform Cambiati Wellness or Dr. Solt MD personnel.

I further understand and acknowledge that Cambiati Wellness Programs, Cambiati Wellness, nor Dr. Solt MD do not manufacture fitness or other equipment, merely provides recreational services and is not liable for defective fitness or other equipment used in its Program. Further, I understand and acknowledge that Cambiati Wellness Programs, Cambiati Wellness, and Dr. Solt MD does not manufacture supplements or other nutritional products recommended through its programs and is not liable for defective products.

I have read the foregoing information and understand it, and have answered the health questionnaire truthfully and completely. Any queries have been answered to my satisfaction.

Rules and Policies

Refunds on Products: We carefully care for our products and due to the delicate nature of the products we cannot return them.  

Appointment Changes: We work hard to prepare for your appointment so please call at least 24 hours prior to your appointment if you need to reschedule. Less than 24 hour notice may result in a loss of a session. Appointments must be completed within 6 months from the sales date unless you have chosen a year-long package.

Refunds on Programs or Private Sessions: We want to hold you at the highest performance level and not completing this program would not serve you. No refunds are given because we want the best for you and because we book time with nutritionists ahead of time. In addition, we do lots of preparation at the beginning of the packages or private sessions. Don’t worry because you are going to love your results!

I have read and agree to be bound by Cambiati Wellness Programs, Cambiati Wellness, and Dr. Solt MD rules and policies, as may be applicable from time to time, which are in place to ensure a safer and more enjoyable environment. Cambiati Wellness Programs, Cambiati Wellness, and/or Dr. Solt MD may, in its sole discretion, modify its rules and policies without notice at any time. I understand that it is my responsibility to know and follow the most current rules and policies. In particular, I understand that I cannot use the facilities or engage in any activity at Cambiati Wellness Programs facilities while under the influence of drugs, alcohol, or medication. Also, Cambiati Wellness Programs does not permit smoking, alcohol or illegal drugs (including steroids) and weapons of any kind, in its facilities. No photography, videotaping, filming or audio recording is permitted on our premises without written permission by an authorized agent of Cambiati Wellness Programs. Cambiati Wellness Programs does not permit and will not tolerate any inappropriate conduct. Such conduct includes, without limitation, using loud, abusive, offensive, insulting, demeaning language, profanity, lewd conduct or any conduct that harasses or is bothersome to other clients. I further understand that if I violate any of these rules and policies, I may be asked to leave and my membership may be terminated without warning, in Cambiati Wellness Programs sole discretion.

Proprietary Program Materials

I understand that all the materials provided to me or which I may have access to in conjunction with my enrollment in Cambiati Wellness Programs, Cambiati Wellness, and/or Dr. Solt MD classes and programs, including without limitation class handouts, teaching materials, emails, presentations, videos, podcasts, slides, website content, exercises, and recipes (collectively the Materials) are confidential. The Materials, including any and all intellectual property rights in the Materials (such as copyrights and trademarks) shall remain at all times the property of Cambiati Wellness Programs. I shall not copy, distribute, display, publish, perform or create derivative works from (by electronic means or in any other way) the Materials without prior written permission from an authorized agent of Cambiati Wellness Programs. This includes forwarding or commercially exploiting the Materials and teaching the Program to others. Neither this agreement nor Cambiati Wellness Programs disclosure of the Materials shall be deemed, by implication or otherwise, to grant me any licensed interest or property right in, under or to any of the Materials and any intellectual property rights therein. These obligations shall survive the expiration or termination of my membership.

Waiver and Release From Liability

I acknowledge that any participation in the Program, use of Cambiati Wellness Programs facilities and/or use of fitness equipment, exercise/nutrition program and/or products or supplements as part of the Program is solely at my own risk. Therefore, I, on behalf of myself and my assigns and heirs, devisees and estate (collectively successors), hereby unconditionally and forever release, discharge and agree to hold harmless Cambiati Wellness Programs, and its affiliates and subsidiaries, along with each of its officers, directors, employees, instructors, volunteers, agents and contractors (collectively, Released Parties), from any and all claims, judgments, costs, damages, losses, expenses and liabilities (whether arising under a theory of contract, warranty, tort, strict liability, product liability or any other theory), relating to any claim I may now or hereafter have with respect to any death, personal injury, property damages, pecuniary loss or other loss, damage cost or expense (collectively Harm) that may be suffered by me or any third party as a result of, or in connection with, the Program, or any portion thereof, the use of Cambiati Wellness Programs facilities, and/or the use of any fitness equipment, exercise/nutrition program and/or products and/or supplements as part of the Program, even if such harm is caused solely by the recklessness, negligence, or fault of one or more Released Parties. I specifically understand and agree that this release will prevent me and my successor from bringing a lawsuit, claim or other action against any Released Party and from recovering any money damages or other legal relief any Released Party or any other released party in connection with any of the claims released above.

Cambiati Wellness Programs is not responsible for any damage, loss or theft of personal property that may occur while visiting our facilities.

If you have registered for class(es) or purchased products online using our website, you might have used pages operated and maintained by a third party. The information that this business collects and maintains as a result of your visit to its web site may differ from the information that we collect and maintain. Cambiati Wellness Programs does not endorse the products or services, or privacy policies of any third-party site. Please review these third-party privacy policies for further information.

THIS WAIVER OF LIABILITY (the “Waiver”) is executed with regard to the referral by Cambiati Wellness to the undersigned (“Client”) to a company, unrelated to Cambiati, LLC or Cambiati Wellness, which provides phlebotomy blood draws. Client wishes to obtain such draw for testing which may be useful to Cambiati, LLC in providing products and related services to Client.

Client understands that the party providing the phlebotomy, IV therapy, or vitamin shots are services unrelated to Cambiati, LLC or Cambiati Wellness.
Client should be aware of certain medical risks and consequences which can arise with regard to any medical procedures, including phlebotomy, IV therapy, or vitamin shots. Client should consult with Client’s professional medical providers if Client has any concerns in this regard.
Client understands that there is a margin of error in any and all tests which labs may run with the sample taken from Client.
It is recommended that Client eat something before the blood draw and have food and appropriate liquid on hand to eat immediately after the draw
Client represents to Cambiati LLC, Cambiati Wellness & Dr. Solt MD that client has the legal right, power, capacity and authority to enter into this Waiver and understands this Waiver and the process of the blood draw.
This Waiver shall be binding on and shall inure to the benefit of both parties and their respective successors and assigns.
Cambiati, LLC, Cambiati Wellness, and Dr. Solt MD may operate as a mandatory mask/face-cover facility. Please comply with that during any visit to the premises as well as during services. Given current conditions, for your protection and as a courtesy to all, we ask that for your visit you shower, wear clean clothes, and comply with all recommended health protections including but not limited to face covering, gloves, keeping good distance apart, and other “best practices.”

If applicable this document will also serve as informed consent for your Intravenous (IV) Infusion Therapy or vitamin shots.

I have informed the IV practitioner of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the staff providing services of my medical history.

Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician’s medical care.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

I understand that: 1. The procedure involves inserting a needle into a vein and injecting a solution. 2. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes. 3. Risks of intravenous therapy include but not limited to: a) Occasionally: Discomfort, bruising and pain at the site of injection. b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death. 4. Benefits of intravenous therapy include: a) Injectables are not affected by stomach, or intestinal absorption problems. b) Total amount of infusion is available to the tissues. c) Nutrients are forced into cells by means of a high concentration gradient. d) Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

Some IVs have high levels of vitamin C at 25000 mg or higher as clinical course dictates. This is not a cure for any disease.  

I am aware that other unforeseeable complications could occur. I do not expect the IV practitioner to anticipate and or explain all risk and possible complications. I rely on the IV practitioner to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV Infusion Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated. My signature below confirms that: 1. I understand the information provided on this form and agree to the all statements made above. 2. Intravenous (IV) Infusion Therapy has been adequately explained to me. 3. I have received all the information and explanation I desire concerning the procedure. 4. I authorize and consent to the performance of Intravenous (IV) Infusion Therapy. 5. I release Dr. Solt MD, Cambiati Wellness, contractors, and staff from all liabilities for any complications or damages associated with my Intravenous (IV) Infusion Therapy.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY. 

Our Legal Duty and Commitment to Privacy 

We are committed to maintaining the privacy of your protected health information (“PHI”).  We are required by law to maintain the privacy of your PHI, provide you with this Notice of Privacy Practices and notice of our legal duties regarding your PHI.  We are also required to follow the practices described in our Notice of Privacy Practices currently in effect.

Uses and Disclosures of Health Information for Treatment, Payment, or Health Care Operations (“TPO”)

We may use or disclose PHI about you for our TPO, including for example:

For treatment purposes (such as sharing information about your care with members of our staff to assist in your treatment or care, or with the physician or hospital that referred you to us, as part of efforts to coordinate your follow-up care), for payment purposes (such as verifying your insurance coverage or providing information needed for your health insurance plan to cover and pay for the claim for services that we provide to you) 
for health care operations (such as our administrative activities, activities to enhance the care that we provide to our clients and their satisfaction with our services, and activities to help make sure that we comply with applicable law). 

We may also disclose your PHI for treatment activities of other health care providers, for payment activities of other health care providers, payors or health care clearinghouses, or for the health care operations of one of those entities if we and that entity each have (or had) a relationship with you and the PHI relates to that relationship.

Other Uses and Disclosures Without Your Written Authorization

We may use or disclose PHI about you without your authorization for several other purposes required or permitted by law.  Subject to certain requirements, we may use or disclose your PHI without your authorization as follows: 

to you upon request or as required by law;
when required by the Secretary of the Department of Health and Human Services;
for public health activities (such as reporting information to agencies authorized by law to collect information for purposes of preventing or controlling diseases, injuries or disabilities; preparing reports to the FDA; maintaining vital health records such as for births and deaths, etc.);
to our business associates;
to your personal representatives;
for certain incidental uses or disclosures;
for face to face communications that we make with you regarding products or services;
to provide gifts of nominal value to you or your family;
to correctional institutions if you are an inmate
to help prevent or control communicable diseases;
to your employer in limited circumstances, typically related to work place injuries or medical surveillance;
for reporting abuse, neglect or domestic violence;
for health oversight activities authorized by law (such as civil or criminal investigations, audits, licensure and disciplinary proceedings, etc. );
for judicial and administrative proceedings (such as in response to court orders or discovery requests);
for law enforcement;
to funeral directors, coroners and medical examiners;
for purposes of organ, eye or tissue donation;
to avoid a serious threat of harm to health and safety;
for specialized governmental functions (e.g., military operations; national security);
for auditing purposes;
for certain research studies;
for workers’ compensation purposes; and 
for emergencies or disaster relief;
to persons involved in your care or payment related to your care;
for notification purposes with respect to your care, condition, location or death.

We may also contact you about appointment reminders, treatment alternatives or for other purposes. 

You acknowledge that you may be in a room with other people. We will make every effort to protect your privacy but please note that an incidental use or disclosure may occur if it cannot reasonably be prevented, is limited in nature, or occurs as a byproduct of another permissible or required use or disclosure. For example, staff speaking with a client in a shared room may result in an incidental disclosure of health information.

In any other situation, we will ask for your written authorization before using or disclosing any of your PHI.  If you sign an authorization to use or disclose information, you can later revoke that authorization to stop further uses and disclosures. 

Individual Rights

In most cases, you have the right to look at or obtain a copy of PHI that we maintain about you.  We may charge a fee for costs related to your request.  We may, under certain circumstances, deny your request but if we do, you can obtain a review of that denial by another licensed health care professional that we designate.

You also have the right to receive an “accounting,” which lists certain instances when we have disclosed PHI about you for reasons other than treatment, payment, or health care operations. The request can cover a time period no longer than six years from the date of disclosure.  Your first request in a 12-month period is free.  After that, we may charge for costs related to additional requests. 

If you believe that information in your record is incorrect, or if important information is missing, you also have the right to request that we correct the existing information or add the missing information.  We have the right to deny such a request under certain circumstances.

You have the right to request that your health information be communicated to you in a confidential manner such as asking that we contact you at work rather than at home. 

You may request that we restrict how we use or disclose information about you for treatment, payment, or health care operations or to persons involved in your care (except when specifically authorized by you, when required by law, or in emergency circumstances).  We will consider your request for such restrictions, but are only bound by them if we agree to them. 

To exercise any of the rights described above, please make a request in writing to our Privacy Official/Contact Person listed on page one of this Notice.

Changes in Our Notice of Privacy Practices

We may change our privacy practices at any time and the new terms shall apply to all PHI about you that we have at the time of the change and to all PHI about you that we maintain in the future.  If we make any material changes, we will change our Notice of Privacy Practices and post it in the waiting area of our office.  The changes will not take effect until they are reflected in a revised Notice of Privacy Practices.  You can request a copy of our Notice of Privacy Practices at any time.  If this Notice of Privacy Practices was sent to you electronically, you have the right to obtain a paper copy upon request.  For more information about our privacy practices, contact our Privacy Official/Contact person listed on the first page of this Notice.

Complaints

If you are concerned that we have violated your privacy rights, you may contact the Privacy Official/Contact Company listed on the first page of this Notice.  You may also send a written complaint to the Secretary of the United States Department of Health and Human Services.  You will not be retaliated against for filing a complaint. 

General Terms

If any provision of this document is found to be unreasonable or unenforceable in any respect by a court, this agreement shall nonetheless be enforced to the maximum extent to which it is found by the court to be enforceable. This agreement is governed by the laws of the state of California, without reference to its choice of laws rules.

I have read and agree to be bound by this agreement:

December 5, 2020

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