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IV Drip Therapy Release Agreement

I understand that information provided by Cambiati Wellness Programs, Cambiati Wellness, and Dr. Terrill Haws 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 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 Programs personnel.

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

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 services coordinated by Cambiati Wellness on behalf of Dr. Terrill Haws for the undersigned (“Client”) to provides IV drip therapy services. 

Client understands that the party providing the phlebotomy, IV therapy, or vitamin shots are services unrelated to Cambiati, LLC and 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 Cambiati LLC may run with the sample taken from Client.
It is recommended that Client eat something before the blood draw or IV and have food and appropriate liquid on hand to eat immediately after.
Client represents to Cambiati LLC 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 or IV therapy.
This Waiver shall be binding on and shall inure to the benefit of both parties and their respective successors and assigns.
Cambiati LLC operates now 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.”

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.

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 Terrill Haws, Cambiati Wellness, contractors, and staff from all liabilities for any complications or damages associated with my Intravenous (IV) Infusion Therapy.

I do not have any history of kidney stones and if so I have informed my practitioner. 

 

I have no known Glucose-6-phosphate dehydrogenase (G6PD) deficiency. 

 

I do not have kidney or active liver disease. 

 

I do not have congestive heart failure or end stage renal disease. 

 

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:

August 8, 2020

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If you are under the care of a physician for a health problem or medical condition please remind us when you are purchasing products and make sure to work with your doctor as well. Please be specific about the problem(s) or condition(s):
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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.
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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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