Consent Form I voluntarily consent to receive Intravenous (IV) Therapy treatment. I understand this involves inserting a small needle into a vein to administer fluids, medications, vitamins, or other therapeutic substances. I acknowledge that, while generally safe, IV Therapy carries inherent risks and potential side effects including but not limited to: Select each of the following as acknowledgment * Potential development of temporary small lumps or nodules at the injection site. Allergic reactions such as itching, rash, hives, and in rare cases, anaphylaxis. Temporary effects such as redness, swelling, bruising, discoloration, seroma, hematomas, or pain at the injection site, with a slight risk of infection. Possible temporary symptoms like dizziness, nausea, headache, nerve irritation leading to numbness or sensitivity. I understand that the listed risks and potential side effects are not exhaustive, and unforeseen risks may arise. I agree to contact my primary care physician and/or seek medical attention at my own expense if I experience any side effects. I understand it is my responsibility to disclose any health conditions or medications that might affect the treatment. I also understand the services provided have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. I understand that Hydrata’s practitioners reserve the right to decline treatment for clients that have vital signs outside of the parameters set in the company’s policy and/or conditions that exclude their eligibility for the above mentioned services. I understand that the material on this form is provided for informational purposes only and is not medical advice. I acknowledge that the practitioners providing treatments and care are entitled to a safe environment free of abusive language, inappropriate contact and/or harassment. In the event of any abuse or inappropriate behavior, the practitioner(s) reserve the right to immediately suspend or discontinue care without further obligation. Pursuant to state and federal HIPPA laws, I understand that as health care providers, Hydrata will not disclose any of my personal health information without my written consent, maintaining confidentiality of my health and medical information. By submitting this form, I confirm that I have received complete information regarding the potential risks, benefits, and alternatives associated with this treatment. I have had the opportunity to ask questions and have my concerns addressed to my satisfaction. I willingly consent to undergo this IV Therapy treatment and release Hydrata, LLC from any liability or claims arising from the procedure. By submitting below, I am also acknowledging my review, understanding and acceptance of Hydrata’s cancellation policy. Name First Name Last Name Email Thank you!
