The IV Hub Smart Waiver
Consent for IV/IM/SQ Therapy
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 intramuscular injection, and/or subcutaneous injection. I understand medical treatment has risks.
The most common risks from IV hydration therapy include but are not limited to an 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 reactions, 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 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 failure to inform the staff about my medical issues and drug use can lead to serious 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 for the 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 the court process of any form except as MA law provides for judicial review of arbitration proceedings. Both parties to this contract, evidenced by the patient's 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 whose 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 mother's expected child or children. Filing by the company of any 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 the potential for blood to blood transmission with the client, the client agrees to obtain formal blood testing to rule out the 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 within 24 hours of needle stick injury at a nearby lab facility.
2. The IV Hub reserves 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 to the use of IV hydration therapy
The procedure set forth above has been adequately explained to me 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.