IV Therapy Patient Consent

ivee Patient Consent

I, the undersigned client, consent to treatment from (i) if in the State of New York or Pennsylvania: IV Medical New York, P.L.L.C (“ivee”) (ii) If in the State of New Jersey: IVEE MEDICAL, P.C. I acknowledge and agree that I understand the risks associated with intravenous (IV) hydration, vitamin intramuscular injection, Venipuncture and the possible other services provided by duly licensed medical professionals. I acknowledge that the services and any medication prescribed, as applicable, has been prescribed based on my honest and truthful description of past medical history and current symptoms. I understand that neglecting to share complete and accurate records may result in personal injury. I confirm and agree with the recommended services and am aware that all matters can be discussed further with the supervising practitioner and/or clinician [registered nurse] at the time of my visit. I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND ANY QUESTIONS I HAVE ASKED HAVE BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY MANNER. I understand that this consent is valid for the date of a single visit and must be completed upon each treatment session moving forward. I understand I may withdraw my consent at any time by written notice to ivee, and if done so, the services will either be stopped immediately or not be provided thereafter, at ivee’s sole discretion. I understand that admission to and continuation of ivee services are subject to ivee’s policies and procedures which includes, but is not limited to, revoking service at any given time should there be an identified unsafe environment for our clinicians. I understand that ivee makes no warranties or guarantees regarding the treatment outcome and despite this, I desire to undergo treatment. I represent that I have received a thorough explanation as to the risks associated with the treatments, including but not limited to, infiltration, phlebitis, hypersensitivity and infection. I understand providers are not “on call”, and do not reply to urgent matters after hours. For any urgent matters, I have been advised to seek an urgent care center, emergency room services or call 911. I have also been advised to continue care with my primary care physician. I understand that I have the right to refuse any treatment or procedure. In the event of an emergency, I consent to the release of any information to any and all parties involved in my medical treatment [ie. physician, hospital, and/or other facility, etc.]. I consent to the release of information by ivee to individuals acting in direct official capacities as my advocate or health care providers involved in my care and treatment. ivee will not receive any payment or other remuneration from any third party in exchange for disclosing your information. I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events associated with the services and will not hold the providers, Ivee App, (i) if in the State of New York or Pennsylvania: IV Medical New York, P.L.L.C (“ivee”) (ii) If in the State of New Jersey: IVEE MEDICAL, P.C. I (the “Releasees”) liable for any unfavorable outcome or adverse event. I release the Releasees, owners, and medical staff from liability associated with any of the services. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns (the “Releasors”). This release shall be governed by the laws of of the State of the Patient's Address. In the event any provision of this release is found to be overly broad in time, scope or otherwise or illegal, invalid, or void for any reason such provision shall be revised to the minimum extent required to make such provision enforceable and valid and the revised provision shall be made a part of this release as if it were set forth in the body of this release. By checking this box, I understand and agree with this consent willingly and voluntarily.


305 Ventures