Informed Consent and Waiver of Liability
_____I have completed and honestly answered all patient questions and was forthcoming with any and all medical conditions, any and all medications and any and all allergies I have, or have had in the past. To the best of my knowledge all the information provided is accurate and complete.
______IV therapy is contraindicated in the following situations: A systolic pressure above 160 and/or a diastolic pressure above 110, kidney disease, renal/kidney failure, any bleeding or clotting disorders, heart disease and individuals taking digoxin, diabetes insipidus, uncontrolled edema or non-compliance with any loop diuretic prescription.
_____IV therapy may cause any of the following adverse reactions: infiltration, phlebitis, hematoma, air embolism, allergic reaction, kidney problems, headache, congestion. In severe cases: anaphylaxis, infection ,cardiac irregularities or cardiac arrest.
_____I will leave bandaging on for 20, no more than 30 minutes after the conclusion of the IV therapy treatment. I understand there may be some bruising, discomfort and bleeding from the IV site.
_____I have been made aware of any potential side effects and potential contraindications. I also understand that unforeseeable conditions could occur, and that HydraMed IV cannot reasonably be expected to anticipate and/or explain all risks and potential complications from IV therapy treatments. I have been given the opportunity to discuss the IV therapy treatment along with the risks and complications in association with the treatment.
_____I acknowledge that I am responsible for any and all medical care I may receive either directly or indirectly as a result of my IV therapy treatment. I also acknowledge that I am solely responsible for payment of my own medical care.
_____I understand English, or have appointed someone to translate this informed consent and waiver of liability in its entirety.
I, the undersigned, on behalf of myself and my legal representatives, heirs, successors and assigns, do hereby release and forever discharge HydraMed IV and its agents, employees, successors and assigns from any and all claims, losses, costs, expenses and damages of any kind involving or related to errors, omissions or negligence in the performance, procedures and administration of the IV therapy. Without limitation, I agree that HydraMed shall not be held liable or responsible for failure to detect any conditions that exist. I have read the agreement, informed consent and waiver of liability, understand its terms, understand that I’m giving up substantial rights by signing it, and that I am signing it freely and voluntarily without inducement, assurance or guarantee made to me. By my signature below, I intend this to be a full, complete and unconditional waiver and release of all liability of HydraMed IV and its agents, employees, successors and assigns to the greatest extent permitted by law