Scheduling Terms

I hereby give my informed consent for the intravenous administration, vitamin therapy, vitals, basic health risk assessments (prior to any service), and/or other related health services (collectively referred to as “IV therapy”) as set forth herein.

I understand that this document is intended to serve as confirmation of informed consent for IV Therapy as ordered by a licensed healthcare provider and facilitated by Hangover Healthcare, LLC.

• I acknowledge that I have completed the medical questionnaire, the Informed Consent, and that all information is/was answered truthfully, honestly, accurately and to the best of my knowledge.
• I have stated all medications prescribed to me and any recreational drugs or over the counter medicines that I have taken in the last 72 hours on the Patient Registration form.
• I acknowledge that if the medical professional believes that I am under the influence or impaired by alcohol and/or illegal drugs, it is the medical professional’s sole discretion to deny me the services requested.
• I have read and agree to the Cancellation Policy Below.

Medical history and personal information divulged during my assessment and IV Therapy will be kept strictly confidential unless I consent to sharing my information by way of a signed release. I understand that I have the right to be informed during the procedure about the risks and benefits, except in emergencies. Procedures are not performed until I have had the opportunity to receive such information and have given my informed consent by executing this document.

The IV Therapy procedure involves inserting a needle and placing a catheter into your vein with the purpose of infusing, over a determined period of time, prescribed nutrients (normal saline with possible additive vitamins, minerals and amino acids). I understand that risks, benefits and alternatives to IV’s may include but are not limited to:

1. The risks and potential side effects:
   1. Discomfort, bruising and pain at the site of injection
   2. Inflammation of the vein used for injection, phlebitis, metabolic disturbances and injury.
   3. c. Severe reaction, anaphylaxis, cardiac arrest or death
2. The benefits:
   1. Injectables are not affected by stomach or intestinal disease.
   2. The total amount of infusions enters the bloodstream and is available to the tissues.
   3. Intravenous hydration allows for an increased absorption of vitamins that cannot always be achieved by oral supplementation. IV therapy avoids the vitamin being broken down in the stomach, which can help avoid irritation to the gastro intestinal tract.
3. Alternatives to IV vitamin therapy are oral supplementation and/or dietary and lifestyle changes.

I understand that IV Therapy is not a substitute for medicine, medical treatment, or the diagnosis, treatment, or cause of disease by a medical provider.

I am aware that other unforeseeable complications could occur. I understand that the Registered Nurse or Advanced Emergency Medical Technician performing the procedure may have to exercise their best judgement during my IV therapy if such complications occur. I understand the risks and benefits of the IV Therapy and was provided the opportunity to have all my questions answered.

I understand I have the right to consent to or refuse any proposed treatment at any time prior to its performance, subject to the cancellation policy below. With that said, I affirm that I have given my consent for IV therapy with any different or further procedures, which in the opinion of my provider(s) or other(s) associated with this practice, may be indicated.