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Pivot Wellness

HIPAA Acknowledgment

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

·      Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly

·      Obtain payment from designated third-party payers.

·      Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of your Notice of Privacy Practices that contains a more complete description of the uses and disclosures of my health information (available at the following link HIPAA Notice of Privacy Practices or in office in print form).

I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this Hydration Company has the right to change its Notice of Privacy Practices from time to time and that I may contact office at any time to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that this business restricts how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the hydration clinic is not required to agree to my requested restrictions, but if they do agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that action has been taken relying on this consent. 

Please list any other parties who can have access to client's health information

Full Name of Person Authorized to Access Patient's Health Information

By signing the box below, I acknowlege that I have received the HIPAA Agreement provided by Pivot Wellness.

Pivot Wellness




Informed Consent and Arbitration Agreement

There is no guarantee that intravenous (IV) hydration therapy will help you achieve relief from hangover effects, migraines, or lack of energy. These symptoms vary greatly and individual results will vary. While many feel relief from hydration therapy, symptoms may return within the first 24 hours of treatment.

 

Please drink alcohol in moderation. Excessive drinking after IV therapy can result in stomach, irritation and other complications. Do not ever drink to excess with the assumption that IV hydration will be able to relieve your symptoms. Excessive drinking can lead to alcohol, poisoning and other serious medical problems. Alcohol poisoning is a very serious, deadly condition. Always drink alcohol in moderation.

 

I hereby grant permission to be treated for my symptoms, including, but not limited to: dehydration, headache, nausea, and vitamin deficiency. I understand that this treatment may involve an intravenous catheter (an “IV”) and/or intramuscular injection and/or subcutaneous injection (each of the intramuscular and subcutaneous injections, an “Injection”). I understand that medical treatment has risks. The most common risks from IV hydration therapy include, but are not limited to allergic reaction to medications, vein irritation, heartburn, fluid overload, kidney problems, headache, and pain at the IV insertion or Injection site. The rarer side effects include, but are not limited to inflammation of the vein used for injection, phlebitis, metabolic disturbances and injury. The extremely rare side effects include, but are not limited to: severe allergic reaction, anaphylaxis, infection, and cardiac arrest. I have informed the nurse and/or other licensed medical profession (each, a “medical professional”) of any known allergies to drugs or other substances or of any past reactions to anesthetics. I have informed the medical professional of all current medications and supplements.

 

Pivot Wellness



Medical History

Gender
Are you experiencing shortness of breath?
Have you recently or currently experiencing any bleeding?
Have you recently or currently experiencing chest pain?
Have you recently or currently experiencing any swelling or edema?
Please place a check if you have any of the following conditions:
Are you taking or been told to take Digoxin?
Have you been told you have decreased GFR or kidney problems?
Could you be pregnant?
Are you breast feeding?
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