Medical History
Surgical History
Current Medical Condition
By Signing below, I hereby agree that all of the above information is true and accurate to the best of my knowledge.
I (patient or legal representative) understand that by signing this agreement I am authorizing RevIVed Hydration PLLC to provide intravenous vitamin/hydration services for the sole purposes of: promoting general wellness, providing symptom relief from headaches, hangovers, muscle aches, or for improving athletic performance, decreasing fatigue and shortening recovery time after intense physical activity. I understand that in order to receive IV vitamin/hydration services by RevIVed Hydration PLLC that an intravenous catheter will be inserted into my vein. I understand that RevIVed Hydration PLLC is treating my symptoms and by no means providing me with a medical diagnosis. I understand that IV vitamin/hydration services affect everyone differently and may not meet my desired results.
I understand and acknowledge that RevIVed Hydration’s practitioners and medical staff take precautions to decrease any risk of health related complications associated with intravenous hydration therapy, vitamin/supplementation administration, pharmaceutical administration and related services. I understand there are potential low risk complications including but not limited to: Infiltration, Phlebitis, Pulmonary Embolism, Air Embolism, Pulmonary Edema, Electrolyte Imbalance, Infection, Bruising, Lightheadedness and Anaphylaxis.
I, the patient, or his or her legal representative, heirs, successors, and assigns, does hereby release and forever discharge RevIVed Hydration PLLC and its agents, employees, successors, and assigns, from any and all claims, losses, cost, expanses, and damages of any kind involving or related to errors, omissions, or negligence in the performance, procedures and administration of the IV vitamin/hydration services.
I expressly represent to RevIVed Hydration that I am not under the influence of any illegal or controlled substance at the time of service. I acknowledge and agree that any injury or harm resulting from the services provided by RevIVed Hydration rest entirely with me if I do not disclose any medical/surgical condition, medication or drug use in advance.
This document is intended to serve as confirmation of informed consent for IV hydration therapy and related services provided by RevIVed Hydration PLLC.
I confirm that I have read this form and understand all content. I understand that no guarantees have been made to me regarding the intended results of services provided by RevIVed Hydration PLLC. I have had the opportunity to ask questions and have them answered to my satisfaction and assume all risk associated with my participation in the services.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Your Rights
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request, after submitting an Authorization for Use and/or Disclosure of Protected Health Information Form. We may charge a reasonable, cost-based fee. You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days. You can complain if you feel we have violated your rights by contacting us at [email protected] or call us at 616-888-5006. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.
Our Uses and Sharing of your Health Information
We can use your health information and share it with other professionals who are treating you. We can use and share your health information to run our practice, improve your care, and contact you when necessary. We can use and share your health information to bill and get payment. We can share health information about you for certain situations such as: preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, preventing or reducing a serious threat to anyone’s health or safety. We can use or share your information for health research. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. We can use and share your health information for law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, for special government functions such as military, national security, and presidential protective services. We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.
