I understand that participating in intravenous (“IV”) hydration, vitamin/supplement administration, pharmaceutical medication administration, programs and services made available by ______ , PLLC (“haus of modern wellness) carries risks. Risks include, but are not limited to, the following: injury, bleeding, infection, inflammation or swelling, bruising or scarring resulting from IV infiltration, extraction and extravasation, misplacement of IV lines in the body, air embolism, fluid overload, medication adverse interactions, nerve injuries, lightheadedness or fainting. To the extent that I fail to disclose any of my health conditions, medications or drug use in advance, I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such a regiment, programs and services rests entirely with me.I expressly represent and warrant to Haus of modern wellness, that I have never been diagnosed with nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in regimens, programs or services made available by haus of modern wellness, and I am not choosing to participate with any expectation that haus of modern wellness will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions. I acknowledge and understand that haus of modern wellness is relying upon the foregoing representations and warranties that I am providing in choosing to accept me for participation in its programs and services. I acknowledge that haus of modern wellness has made no warranties or guarantees as to the results or general success of the IV hydration, vitamin or supplement administration, pharmaceutical medication administration (e.g., iron infusion), programs or any other services made available by haus of modern wellness and all expressions made by haus of modern wellness relative thereto, are opinions that should not be relied upon. Please drink alcohol in moderation. Heavy drinking after IV hydration therapy can lead to stomach irritation or other complications. IV hydration therapy is not a cure for heavy drinking. I acknowledge that ancillary damages may occur to my property as a result of participating in IV hydration, vitamin/ or supplement administration, pharmaceutical medication administration (e.g., iron infusion), programs and services including, but not limited to, damages caused by blood staining my property. I hereby hold haus of modern wellness entirely harmless and will fully indemnify haus of modern wellness against all such damages. 

I acknowledge that the services provided have not been evaluated by the FDA. I acknowledge that these products are not intended to diagnose, treat or cure any disease. I expressly represent and warrant to haus of modern wellness that I am not a user of illegal drugs and/or controlled substances and I am not under the influence of the same or recovering from use of the same at the time of the provision of services to me. In the event of an emergency, I will be sure to call 911 or proceed to the nearest emergency room. 

Acknowledgement: I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by haus of modern wellness. I understand the nature of the sessions and programs and that participating in them carries risks. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction. I agree to my assumption of all risks associated with my participation. 

Patient Authorization for Use and Disclosure of Protected Health Information: 

By signing, I authorize haus of modern wellness to use and/or disclose certain protected health information (“PHI”) about me if needed. This authorization permits haus of modern wellness to use and/or disclose the following individually identifiable health information about me include, but are not limited to: date(s) of services, type of services, origin of information, age, gender, and vital signs. The information will be used or disclosed for the following purpose: obtaining research data to reflect growth, sales, and types of services requested by our client population. The purpose is provided so that I can make an informed decision whether to allow release of the information. This authorization will expire one (1) year from date of service. The practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI. I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. 

I hereby give haus of modern wellness, and any and all employees and/or agents, the right and permission to use and/or publish photographs of me for art and promotional purposes including but not limited to, advertising, publicity, commercial or display of use. Also authorize my photos to be posted on social media, such as Facebook, Twitter, TikTok, and the office's website page. I hereby release and discharge haus of modern wellness, and all persons functioning under haus of modern wellness, permissions or authority from any legal or equitable claims including but not limited to the following: blurring of the image(s), alteration, distortion or use in composite form, libel, invasion of privacy or any claims based on the production or in the process of recording or publishing the materials. Photos may be taken during sessions. All participants consent to haus of modern wellness using their name, image and/or quote for any promotion and that all proprietary rights including property rights of any image, photograph or likeness of yourself will be owned by haus of modern wellness. You agree that your name, image and/or quotes may be used in any medium including but not limited to provision of footage to the media, Website or Facebook Page for haus of modern wellness. 

I consent to email, text and phone communications related to post-procedure care and follow-up appointments. I consent to receive promotional messages and marketing messages via email, phone and SMS messages from Haus of modern wellness. 

I will sign below to agree to the above terms: