Agreement Consent & Release of Liability
The undersigned (or “Patient”) agrees to the intravenous (IV) vitamin therapy administration by The Vessel IV Bar of Texas, LLC ("The Vessel IV Bar ATX") for the limited purpose of boosting athletic performance or reducing fatigue and shortening physical illness recovery time from participating in the Event described below. Patient understands IV vitamin therapy affects patients in various ways and may not meet Patient’s desired results. Patient understands that unless a Patient comes with a physician's order for the services of The Vessel IV Bar of Texas, LLC, the Patient is not under the care of a physician, midlevel provider, or the medical director of The Vessel IV Bar of Texas, LLC and have chosen to undergo vitamin therapy by his or her own choice, without medical recommendations from The Vessel IV Bar of Texas, LLC, its medical director, or its employees. IV vitamin therapy is provided for pre or post-event health optimization purposes only, does not in any way constitute a medical diagnosis, and that additional screening or procedures not provided by The Vessel IV Bar ATX might be required in the event a medical diagnosis is desired. Patient acknowledges and agrees it is their sole responsibility to consult with the Patient’s personal health care provider with regard to his or her health concerns and to obtain any follow-up care determined by that health care provider to be appropriate. Further, Patient understands that this screening is not a complete physical exam, and is not a substitute therefore. Patient further understands that the administration of IV vitamin therapy requires a prick to Patient’s skin and Patient may experience some pain, inflammation/swelling, redness, bruising, and soreness around the injection site.
The undersigned agrees that he or she has truthfully disclosed all of Patient’s health related history and information requested. Patient understands that The Vessel IV Bar ATX will not provide Patient’s medical health information to any physician or health care provider for any further review of any health condition that may be disclosed by patient.
The undersigned, on behalf of him or herself and his or her legal representatives, heirs, successors and assigns, does hereby release and forever discharge The Vessel IV Bar ATX 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 vitamin therapy. Without limiting the foregoing, the undersigned agrees that if any condition exists that is not detected by the pre-IV vitamin therapy screening, The Vessel IV Bar ATX and its agents, employees, successors and assigns, shall not be held liable.
I hereby grant permission to be treated for my symptoms, including, but not limited to: dehydration, acetaldehyde toxicity, 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 the medical treatment includes risks. The most common risks from hydration therapy include but are not limited to: allergic reaction to medications, vein irritation, heartburn, fluid overload, kidney problems, headache, and pain or bruising 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 disturbance 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 doctor, nurse and/or other licensed medical professional (each, a “medical professional”) of any known allergies or other substances or of any past reactions to anesthetics. I have informed the medical professional of all current medications and supplements.
I am aware that other unforeseeable conditions could occur. I do not expect the medical professional(s) to anticipate and/or explain all risks and possible complications. I rely on the medical professional(s) to exercise judgment during the course of treatment. I acknowledge that I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications, and consequences associated with the procedure. My questions have all been answered in terms I understand. I am aware of the risks and potential side effects if I undergo hydration therapy.
I have truthfully answered all questions regarding my medical history and have informed the staff about any and all prescription and/or over-the-counter drugs I take, as well as any street or recreational drugs. I understand that failing to inform the staff about my medical issues and drug use can lead to serious complications.
I acknowledge that I am responsible for any medical care I have directly or indirectly related to my hydration therapy treatment. If there is an allergic reaction or otherwise, I agree that I am responsible for payment of my medical care.
I represent and warrant that I understand the risks associated with hydration therapy. I hereby waive any and all claims and agree to hold The Vessel IV Bar ATX harmless regarding any adverse reaction(s) I may have during the following hydration therapy treatment.
I acknowledge that it is unlawful to advertise that a product or service can prevent, treat, or cure human disease unless possessed competent and reliable scientific evidence, including, when appropriate, well-controlled human clinical studies, substantiating that the claims are true at the time they are made. For COVID-19, no such study is currently known to exist for the products or services identified above. The Vessel IV Bar of Texas, LLC has not made any coronavirus-related prevention or treatment claims regarding such products or services and thus are not supported by competent and reliable scientific evidence.
Agreement to arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompletely rendered, will be determined by submission to arbitration as provided by Texas law and not by a lawsuit or resort to court process of any form, except as Texas law provides for judicial review to arbitration proceedings. Both parties to this contract, evidenced by patient’s signature below and The Vessel IV Bar ATX’s acceptance of such signature, are voluntarily waiving their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration. All claims must be arbitrated. It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies, whether lying in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by any physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers associated with The Vessel IV Bar ATX (collectively herein referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether bon or unborn at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing the Physician of any action in any court by the Physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.
Procedures and Applicable Law: A notice or demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his or her attorney. The parties shall thereafter select a mutually agreeable arbitrator to precede over the matter. Both parties agree the arbitration shall be governed pursuant to applicable Texas state law. The parties shall bear their own costs, fees, and expenses, along with a pro rata share of the arbitrator’s fees and expenses.
Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of this agreement enforced in accordance with Texas and federal law.
My signature below confirms that:
1. I am 18 years or older and am of sound legal mind to authorize and consent to the use of hydration therapy.
2. The procedure set forth above has been adequately explained to me by my attending medical professional.
3. I have received all the information and explanation I desire concerning the procedure.
4. This documentation is intended to serve as confirmation of informed consent for intravenous vitamin and/or hydration therapy administration by The Vessel IV Bar ATX.
I HAVE READ THIS AGREEMENT, CONSENT AND RELEASE OF LIABILITY, UNDERSTAND ITS TERMS, UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE MADE TO ME. FURTHER, I INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY OF THE VESSEL IV BAR ATX AND ITS AGENTS, EMPLOYEES, SUCCESSORS AND ASSIGNS TO THE GREATEST EXTENT ALLOWED BY LAW.