Consent forms

I understand that my medical evaluation may be completed by telehealth, which allows me to meet with a licensed healthcare provider by video, phone, or other electronic communication when we are in different locations.

I understand that:

• Telehealth has some limitations compared with an in-person visit.
• Technical problems or interruptions may occur.
• My health information will be handled according to applicable privacy laws.
• The provider may determine that an in-person evaluation or a different level of care is needed.
• Telehealth is not appropriate for medical emergencies. If I am experiencing an emergency, I should call 911 or seek emergency medical care.
• I may ask questions and may withdraw my consent to telehealth at any time.
• Completing a telehealth evaluation does not guarantee that I will be approved for IV therapy or another treatment.

I have read and understand the information above and consent to receiving healthcare services by telehealth.

I consent to receive IV therapy ordered by an authorized healthcare provider and administered by a licensed healthcare professional.

IV therapy involves placing a small catheter into a vein to administer fluids and may include vitamins, minerals, nutrients, medications, or other ingredients included in my prescribed treatment.

Benefits

IV therapy may be used for hydration and other wellness purposes depending on the treatment ordered. Individual results vary, and no specific result or benefit is guaranteed.

Risks

I understand that IV therapy may cause side effects or complications, including:

• Pain or discomfort during IV placement
• Bruising or bleeding
• Swelling, infiltration, or irritation of the vein
• Infection
• Dizziness or fainting
• Nausea, headache, or flushing
• Changes in blood pressure or heart rate
• Fluid or electrolyte imbalance
• Reaction to an ingredient or medication
• Allergic reaction, including rare serious allergic reactions
• Rare complications that may require emergency medical care

I understand that individual medications or ingredients may have additional risks.

Alternatives

IV therapy is elective. I may choose not to receive treatment. Alternatives may include oral hydration or supplements, seeing my primary care provider, or seeking urgent or emergency medical care when appropriate.

My Responsibilities

I agree to provide accurate information about my medical history, medications, allergies, pregnancy or breastfeeding status, and previous reactions to treatment.

I will tell the nurse immediately if I experience pain, burning, swelling, dizziness, nausea, chest discomfort, shortness of breath, itching, rash, or any other concerning symptom during treatment.

I understand that:

• Signing this consent does not guarantee that I am eligible for treatment.
• Treatment requires appropriate medical evaluation and authorization.
• The nurse or provider may delay, pause, stop, or decline treatment when medically appropriate.
• I may ask questions at any time.
• I may withdraw my consent and request that treatment be stopped at any time.
• RESET Lounge provides elective outpatient services and is not an emergency department. Emergency medical services may be called if necessary.

I have had the opportunity to ask questions about the treatment, its possible benefits, risks, and alternatives. I understand the information above and voluntarily consent to IV therapy.

I acknowledge that I have received or have been given access to RESET Lounge's Notice of Privacy Practices, which explains how my health information may be used and disclosed and describes my privacy rights.

We reserve appointment time specifically for each client. A deposit may be required to reserve your appointment.

Cancellations

Please cancel or reschedule at least 12 hours prior to your scheduled appointment. Late cancellations may result in forfeiture of your deposit.

No-Shows

If you do not attend your appointment and have not canceled within the required time, your deposit will be forfeited.

Late Arrivals

If you arrive more than 15 minutes late, we may need to reschedule your appointment if there is not enough time to safely complete your service. Your deposit may be subject to the cancellation policy.

If Treatment Cannot Be Provided

If RESET Lounge determines that your treatment cannot proceed because of a medical or safety concern, this will not be considered a no-show.

If RESET Lounge needs to cancel your appointment, your deposit will not be forfeited.

I have read and agree to the RESET Lounge Appointment & Cancellation Policy.