Peak IV Hydration, LLC 

906 Sevier Avenue Suite 120,  Knoxville, Tennessee 37920

865-281-5263 | Info@PeakIVHydration.com

Intravenous Nutrient Therapy Consent Form

THANK YOU for choosing Peak IV Hydration, LLC to provide your intravenous nutrient therapy. We appreciate your trust and look forward to working with you. This document is intended to serve as informed consent for your nutrient therapy. In order to prevent any misunderstanding and to better serve you, we ask that you read and initial each paragraph below:

I authorize Peak IV Hydration, LLC to assist me in intravenous therapy. I understand that Peak IV Hydration, LLC is treating my symptoms and is not making any medical related diagnosis. I understand this that this procedure may be considered medically unnecessary. It may or may not mitigate, alleviate or cure the condition for which it is being prescribed.

I understand it is my responsibility to list any and all health/medical history, allergies and medications currently being taken and I have made a full disclosure to Peak IV Hydration, LLC of all health/medical history, allergies and current medications.

I understand the procedure involves inserting a needle into my vein and injecting the prescribed solution.

I understand that Peak IV Hydration, LLC, practitioners and medical staff take every precaution to decrease any risk of health related complications associated with Inter Muscular (“I/M”) Injections and/or Intravenous (“IV”) administration, but there is still an extremely low risk of complications including, but not limited to: infection at IM/IV site; pain, swelling or burning around IM/IV site, fever, chills, metabolic disturbances, Phlebitis, thrombophlebitis, bruising or injury from vein puncture, allergic reaction, anaphylaxis, fluid overload, lowering of blood sugar levels, nerve injuries, air embolism, congestive heart failure or other life threatening reactions. I understand the risks and benefits of the procedure; I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

I understand that I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment to the fullest extent allowed by law. I waive any claim in law and equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to the negligent administration of the procedure.

I understand that IV/IM infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration and are not intended to diagnose, treat, cure or prevent any medical disease. These infusions are not a substitute for your physician’s medical care.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. I have been given the opportunity to ask questions and all my questions have been answered fully and to my satisfaction.

I understand that a follow up with my primary care physician is advised after treatment.

I understand all treatments are provided after consult, Peak IV Hydration, LLC reserves the right to refuse service, postpone therapy, or refer clients to specialized providers as indicated by special needs.

I understand no guarantees or promises have been made to me regarding the outcome of the treatment.

I authorize Peak IV Hydration, LLC to photograph, video and/or use any other mediums which result in the permanent documentation of my image for safety, medical, scientific, marketing or educational purposes. I agree that any such photographs taken pursuant to this authorization, which are not required by law to be retained, may be disposed of by the company so long as the manner of disposition shall be permanent destruction.

I understand and agree to contact Peak IV Hydration, LLC if, after treatment, I experience any symptoms I am not comfortable with.

I understand that payment is due in full at the time of service; Peak IV Hydration, LLC does not bill insurance companies on my behalf. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. I have been given sufficient information to make an informed decision to consent to treatment. My signature below on this form affirms that I have given my consent to intravenous nutrient therapy.

I expressly represent and warrant to Peak IV Hydration, LLC that I am not a user of illegal drugs and/or controlled substances other than those lawfully prescribed to me and which I have fully disclosed to Peak IV Hydration, LLC; I am not under the influence of the same or recovering from use of the same at the time of provision of services.

Acknowledgment of Privacy Practices

I have been informed of my rights to privacy regarding my protected health information as it relates to the Health Insurance Portability and Accountability Act of 1996 (HIPAA I understand that my protected health information may be used and disclosed by my physician, office staff, and others outside of these offices who are involved in my care and treatment for the purpose of providing health care services. I understand that my protected health information may be used to provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly. Although all NPs, RNs and infusion center staff will attempt to conceal written medical information, I understand that other patients or staff in the infusion center may overhear the staff when medical information is provided to me. I further acknowledge that the infusion center is an open treatment area that may be monitored by video surveillance. By signing this page I give my consent to be monitored and recorded by video. I understand that I may request in writing that Peak IV Hydration, LLC restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations and I understand Peak IV Hydration, LLC is not required to agree to my requested restrictions, but if it does agree then it is bound to abide by such restrictions.