IV Therapy Management Agreement

This agreement between_____________________________________ (“Patient”) and --------------------------(PP) establishes guidelines and conditions for the use of IV Vitamin and Hydration Therapy. PP and patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and therefore, these agents are prescribed with caution. The patient agrees and accepts the following conditions:

1. I understand that the Vitamins I am receiving for me based on diagnoses derived from my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions in accordance with applicable state and federal law. 
2. I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.
3. I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
4. I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effects related to my treatment to------------------------and discontinue use until advised to resume usage by my health care provider. I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy.
5. I understand that representatives of ------------------------ and/or licensed Physicians Assistants are available for questions and/or concerns during normal business hours throughout the course of my treatment.
6. I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided by ------------------------ or its associated providers are to be paid in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third-party payer.
7. I agree that the--------------------------physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by -------------------------will be in conjunction with the care provided by my current PCP.
8. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container. 

I have read and agree to the terms of this Therapy Management Agreement.