PREGNANCY TEST WAIVER
I hereby understand that Hydro Pros has requested a pregnancy test prior to my elective treatment and medication administration. However, I am opposed to having this test done. I understanding that should I be pregnant, there is risk to my unborn child in terms of spontaneous abortion and/or birth defects. By signing this waiver, I release Hydro Pros and any associated healthcare providers from liability based on this decision.
Client Presentations, Warranties, and Disclaimer Agreement
I understand that participating in intravenous hydration (iv), vitamin/supplement administration, pharmaceutical administration, programs and services made available by Mobile Healthcare Solutions LLC carries risks.
I ACKNOWLEDGE AND AGREE THAT THE SOLE RISK OF INJURY OR HARM RESULTING IN ANY MANNER FROM MY CHOOSING TO PARTICIPATE IN SUCH REGIMEN, PROGRAMS AND SERVICES RESTS ENTIRELY WITH ME TO THE EXTENT THAT I DO NOT DISCLOSE MY HEALTH CONDITIONS, MEDICATIONS OR DRUG USE IN ADVANCE.
I expressly represent and warrant to Mobile Healthcare Solutions LLC 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 Mobile Healthcare Solutions LLC nor will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.
I acknowledge and understand that Mobile Healthcare Solutions is relying upon the foregoing representations and warranties from me upon Mobile Healthcare Solution’s acceptance of me for participation in its HydroPros Rehydration program and services.
Risks of Services:
INJURY, BLEEDING, INFECTION, INFLAMMATION/SWELLING, BRUISING OR SCARRING RESULTING FROM IV INFILTRATION, EXTRACTION AND EXTRAVASTATION
LIGHTHEADEDNESS OR FAINTING
MEDICATION ADVERSE INTERACTIONS
MISPLACEMENT OF IV LINES IN THE BODY
YOU EXPRESSLY REPRESENT AND WARRANT TO HYDROPROS THAT YOU ARE NOT A USER OF ILLEGAL DRUGS AND/OR CONTROLLED SUBSTANCES AND ARE NOT UNDER THE INFLUENCE OF SAME OR RECOVERING FROM USE OF SAME AT THE TIME OF THE PROVISION OF SERVICES TO YOU.
IN THE EVENT OF AN EMERGENCY CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM
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 Mobile Healthcare Solutions LLC. 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 is required for any disclosures of PHI (protected health information). A record of your treatment will be created regarding services that you have received. Federal and state law mandate that we must follow the Notice of Privacy practices that in effect at the time of disclosure. We are committed to your privacy.
Your PHI may be used in the following ways:
I have read the above and agree to the terms and consent to participate in the Mobile Healthcare Solutions LLC program administrated by HydroPros.
PHOTO AND VIDEO CONSENT
I, (the “Releasor”) grant permission and consent to Mobile Healthcare Solutions LLC DBA Hydropros (the “Releasee”) for the use of the following photograph(s) as identified below for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content:
Description: General photo(s)/video(s) taken during events or procedures
I understand that there shall be no payment for this release.
I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
I understand that with my authorization below the photograph(s) or video(s) may never be revoked.
We, the Releasor and Releasee, understand and agree to the aforementioned terms and conditions.
If this release is obtained from a presenter under the age of 18, then the signature of that presenter's parent or legal guardian is also required.
We take your care seriously, please answer the following questions truthfully so that we may provide you the best service and experience that we may offer. We appreciate you choosing our service.