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The IV Hub 

469 Salem St

Suite 23

Medford, MA 

781-799-2827

The IV Hub Smart Waiver

 

There is no guarantee that intravenous (IV) hydration therapy will help you achieve relief from hangover effects, migraines, lack of energy, or illness. These symptoms vary greatly and individual results may vary. While many may feel relief from hydration therapy, symptoms may return within the first 24 hours of treatment.

 

Please drink alcohol in moderation; Excessive drinking after IV therapy can result in stomach irritation and other complications. Do not ever drink to excess with the assumption that IV hydration will be able to relieve your symptoms. Excessive drinking can lead to alcohol poisoning and other serious medical problems. Alcohol poisoning is a very serious, deadly condition. 

 

I hereby grant permission to be treated for my symptoms, including but not limited to, dehydration, headache, nausea and vitamin deficiency. I understand that this treatment may involve an Intravenous (IV) catheter, and/or an intramuscular injection and/or a subcutaneous injection. I understand medical treatment has risks.

The most common risks from IV hydration therapy include, but are not limited to allergic reaction to medications, vein irritation, heartburn, fluid overload, kidney problems, headache and pain at the IV insertion site or injection site.

 

The most rare side effects include but are not limited to: severe allergic reaction, anaphylaxis, infection and cardiac arrest. I have informed the nurse or other licensed medical professional, of any known allergies to drugs or other substances or any past reactions to anesthetics. I have informed the medical professional of all current medications and supplements.



I am aware that other unforeseeable conditions could occur. I do not expect the medical professional to anticipate or explain all risks and possible complications. I rely on the medical professionals to exercise judgment during the course of the treatment. 

 

I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications and consequences associated with the procedure. My questions have all been answered in terms I understand. I am aware of the risks and potential side effects if I undergo IV hydration therapy.

 

I have truthfully answered all questions regarding my medical history and have informed the staff about any prescriptions, over the counter and street/recreational drugs I take. I understand that failing to inform the staff about my medical issues and drug use can lead to serous complications.

 

I acknowledge that I am responsible for any medical care I have directly or indirectly related to my IV hydration therapy treatment. If there is an allergic reaction or otherwise I agree that I am responsible form payment of my medical care.


I represent and warrant that I understand the risks associated with hydration therapy. I hereby waive any all claims and agree to hold The IV Hub, LLC harmless regarding any adverse reactions I may have during or following the IV hydration therapy treatment. 

 

Agreement to arbitrate. It is understood that any dispute as to medical malpractice, that is to whether, any medical services rendered under this contract were unnecessary, or unauthorized, or were improperly negligently or incompetently rendered, will be determined by submission as provided by MA law and is not by a lawsuit or resort to court process of any form except as MA law provides for judicial review of arbitration proceedings. Both parties to this contract, evidenced as patients signature below and The IV Hub’s acceptance of such signature, are voluntarily waiving their constitutional right to have any dispute decided in a court of law before a jury and instead are accepting the use of binding arbitration. 

 

All claims must be arbitrated. It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies, where lying in tort, contract or otherwise and shall bind all parties who’s claims may arise out of or in any way relate to treatment or series provided or not provided by any physician, nurse practitioner, nurse, medical group or association, their partners or associates, or employees associated with The IV Hub to a patient, any children (born or unborn) at the time of the occurrence giving rise to any claim.  In the case of any pregnant mother, the mothers expected child or children. Filing by the company of any of action in any court by the company to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim against The IV Hub, any fee dispute whether or not the subject of any existing court action shall also be resolved by arbitration.

 

Procedures and applicable law. A notice or demand for arbitration must be communicated in writing by US mail, postage prepaid to all parties, describing the claim against the physician, nurse, nurse practitioner EMT, licensed healthcare provider, the number of damages sought, and the names, addresses, and telephone numbers of the patient, and his/her attorney, The parties shall thereafter select a mutually agreeable arbitrator to preside over the matter. The parties shall bear their own costs, fees, and expenses along with a pro-rata share of the arbitrator's fees and expenses.

 

Severability provision. In the event of any provision/provisions of this agreement is declared void and or unenforceable, such provisions shall be deemed severed there from and the remainder of this agreement enforced in accordance with MA and federal law.

1. Should a staff member of The IV Hub have a needle stick injury with potential for blood to blood transmission with client, client agrees to obtain formal blood testing to rule out potential of communicable diseases transmission via OSHA standards (HIV, Hepatitis etc.) The IV Hub assumes all costs of further necessary testing. Testing shall be performed with in 24 hours of needle stick injury at nearby lab facility.

2. The IV Hub reserve the right to refuse to initiate or continue IV treatment at any time based on RN or licensed healthcare provider staff discretion

 

My signature below confirms that:

 

I am 18 years or older and am of sound legal mind to authorize and consent the use of IV hydration therapy

 

The procedure set forth above has been adequately explained to my by my attending medical professional

 

I have received all the information and explanation I desire concerning the procedure

I do not have liver disease, kidney disease or congestive heart failure

This document is intended to serve as confirmation of informed consent of IV treatment for IV hydration therapy

First Patient Name

First Name*

Middle Name

Last Name*

Phone*
First Patient Date of Birth*
First Patient Signature*
Second Patient Name

First Name*

Middle Name

Last Name*
Second Patient Date of Birth*
Third Patient Name

First Name*

Middle Name

Last Name*
Third Patient Date of Birth*
Fourth Patient Name

First Name*

Middle Name

Last Name*
Fourth Patient Date of Birth*
Fifth Patient Name

First Name*

Middle Name

Last Name*
Fifth Patient Date of Birth*
Sixth Patient Name

First Name*

Middle Name

Last Name*
Sixth Patient Date of Birth*
Seventh Patient Name

First Name*

Middle Name

Last Name*
Seventh Patient Date of Birth*
Eighth Patient Name

First Name*

Middle Name

Last Name*
Eighth Patient Date of Birth*
Ninth Patient Name

First Name*

Middle Name

Last Name*
Ninth Patient Date of Birth*
Tenth Patient Name

First Name*

Middle Name

Last Name*
Tenth Patient Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

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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