Notice of Privacy Practices in accordance with the HIPAA federal regulations this establishment will not disclose any information about your personal health without your permission. All information received while a patient (and/if you declined to be a patient no longer) will be kept confidential. By signing this form, you consent to the use and disclosure of your protected health information by our staff, and our business associated strictly for the purpose of treatment, payment, and health care operations. By signing this form, I grant my consent for the practice to use and disclose my protected health information for the purposes of treatment, payment, and health care operations.

Patients will fill out intake forms and sign consent forms before their first appointment. Failure to have them completed before your appointment time may result in your appointment being rescheduled, and any late cancellation/reschedule fees may apply.

Patients must fill out the intake forms as accurately as possible, as it is of the utmost importance for the practitioner to be aware of any medical conditions or medications that may make a patient ineligible for safe IV therapy.

Before treatment, your practitioner will review and confirm the details in your medical history in order to determine your eligibility for safe IV therapy.

Patients must fill out intake forms and consents yearly.

Prior to receiving treatment, I have been candid in revealing any condition that may influence this procedure as outlined. I will also inform my practitioner of any changes in my medical history, current medications, and/or changes relevant to this procedure or prior to any future treatments. I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I certify that the preceding medical, medications, and personal history statements are true and correct. I am aware that it is my responsibility to inform my practitioner of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists’ day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee of $50 to the card on file.

At times we may use photographs, videos, and/or case information for the following clinical purposes: on our website and/ or social media outlets. Patient consent is voluntary. Patients may refuse to sign this authorization and such refusal will have no effect on the medical treatment they receive.