Vitality Infusions Forms
Date: January 28, 2023
Demographic FormPlease complete all boxes
Date of Birth:
Please list any known allergies and any medications :
Any disorder of the heart or blood vessels, e.g., heart attack, angina pectoris, stroke, palpitations, elevated blood pressure, shortness of breath, chest pain, irregular pulse or varicose veins?
If yes, explain:
Any disease of the stomach, liver, intestines or rectum, e.g., ulcers, gallbladder disease, bleeding from intestinal tract, colitis, diverticulitis or appendicitis?
Any disorder of the prostate, bladder, kidneys or genitourinary tract, e.g., nephritis, sugar, protein or pus in urine, venereal disease, kidney stones or colic?
Anything else, e.g., cancer, cyst or tumor, blood disorder, hypoglycemia, diabetes, g!andularcondition, e.g., thyroid, hernia, skin disease or eczema?
Do you have a vascular port placed?
I submit an accurate and completed form.
Article 1: Agreement to Arbitrate: The patient, ___________, and his/her heirs and assigns, and Vitality Infusions, LLC (“Provider”), and the undersigned Medical Care Provider (“MCP”), including but not limited to any affiliated physicians, employees, contractors, agents and related medical group, professional association, or any other entity or individual which has provided medical services in conjunction with the MCP, agree to submit all disputes whatsoever to binding arbitration including without limitation any claim for malpractice, personal injury, battery, breach of express or implied contract, loss of consortium, wrongful death, non-payment or any other disputes relating in any way to past, present or future medical care. All disputes will be submitted to binding arbitration with the American Arbitration Association. The arbitration process shall be governed the Federal Arbitration Act, state law notwithstanding. It is the express intention of the parties that binding arbitration shall be the exclusive and sole remedy. It is the specific intention of the parties to submit any question concerning this Agreement’s arbitrability to the arbitrators only and to no other person or entity. For all issues regarding the validity of this Agreement, or decided under this Agreement, the prevailing party shall be entitled to attorney’s fees and to costs as determined by the Arbitrator.
Article 2: Recovery: The signers agree that the maximum total amount of all noneconomic and economic damages combined shall never exceed $250,000.00, applied on a per case basis, regardless of the number of claimants seeking compensation, and regardless of the number of physicians, professional associations, employees or entities named as defendants. The Patient agrees to waive any and all rights to a higher award. “Noneconomic damages” means non-financial losses that would not have occurred but for the injury giving rise to the cause of action, including pain and suffering, inconvenience, physical impairment, mental anguish, disfigurement, loss of capacity for enjoyment of life, and other non-financial losses.
The parties agree punitive damages shall not be awarded by the Arbitrator. The Parties further agree that any award by the Arbitrator that exceeds $10,000.00 shall be paid in equal annual installments over the following ten-year period without being reduced to present value. The Provider and the MCP shall be entitled to a set-off for any monies received by the Patient for claims against any other health care provider, if such claims arise out of or relate in any way to the claims of the Patient against the MCP or Provider. The parties agree to the complete disclosure of all collateral sources of compensation
Article 3: Severability: If any specific term or provision of this Agreement is determined by a court of competent jurisdiction to be illegal, invalid, or otherwise unenforceable, the entire remainder of this Agreement shall be construed to be in full force and effect, and all other provisions will still apply. The Parties agree in general that any provisions so challenged will be brought to the arbitrators to decide upon, and not to a judge or jury.
Article 2: All Claims Must be Arbitrated: The patient, and/or his or her spouse, born or unborn children, parents, heirs, or anyone launching any legal or equitable action (hereinafter “the Patient”) and the MCP agree that any complaint of any type which in any way relates to medical services shall, without exception, be submitted to binding arbitration. The governing law shall be the Federal Arbitration Act, state law notwithstanding. It is the express intention of the parties that any and all claims or complaints of any kind shall be submitted to and resolved by binding arbitration, which will be the exclusive and sole remedy. It is the specific and irrevocable intention of the parties to submit any question concerning this Agreement’s arbitrability to the arbitrators only and to no other person or entity. For all issues regarding the validity of this Agreement in court, the prevailing party shall be entitled to attorney’s fees and to costs as determined by the court.
The MCP and any affiliated medical service provider that chooses to join in this Agreement agree to be equally bound just as the Patient is bound to binding arbitration in the event of any dispute. Such disputes can be brought by the MCP against the Patient, including terms of payment, services rendered, physical or emotional abuse, and other disputes. The Patient understands that any and all medical care provided is sufficient consideration, and the Patient will be fully and legally bound by this Agreement. Both parties to this Agreement are giving up their constitutional right to have any dispute decided in a court of law before a jury. All parties understand that they are giving up their right to have any dispute decided by a judge or jury through the court system. Resorting to the legal system by action at law or in equity will only be permissible if necessary to enforce any decisions reached through arbitration. The parties agree that any dispute about any provisions of this Agreement will be decided through arbitration.
The parties hereby bind anyone whose claims may arise out of or relate to treatment or services provided by the MCP at the time of the occurrence giving rise to the claim. In the case of any pregnant mother, the term “patient” means both the mother and the mother’s expected child or children. The parties consent to the participation in this arbitration of any person or entity that would otherwise be a proper additional party in a court action if they have been involved in any way in the care of the Patient. This may include claims of the Patient against other physicians, nurses or medical professionals, or a hospital or other facility. Additionally, this Agreement is intended to resolve all claims for vicarious liability of the MCP.
Article 3: Recovery: The signers agree that the maximum total amount of all noneconomic and economic damages combined shall never exceed $250,000.00, applied on a per case basis, regardless of the number of claimants seeking compensation, and regardless of the number of physicians, professional associations, employees or entities named as defendants. The Patient agrees to waive any and all rights to any higher award. This limitation applies regardless of whether another healthcare provider, such as a physician, a hospital or other facility or employees of such a physician, hospital or facility are named as defendants in the binding arbitration or in any other proceedings. “Noneconomic damages” means nonfinancial losses that would not have occurred but for the injury giving rise to the cause of action, including pain and suffering, inconvenience, physical impairment, mental anguish, disfigurement, loss of capacity for enjoyment of life, and other nonfinancial losses to the extent the claimant is entitled to recover such damages under general law, including the Wrongful Death Act. The arbitrators may choose to award damages in excess of $250,000.00 only when extreme hardship is demonstrated. As consideration for the limitation on any waivers, the MCP will pay up to and only the first $2,500.00 of attorney fees for the Patient.
The parties agree that if any punitive damages are awarded, they may not exceed three times any compensatory award. Same as required by Medicare/Medicaid, the parties agree that any awards in excess of $10,000.00 shall be paid in equal annual payments over ten (10) years without being reduced to present value. The arbitrators may reduce the time period in cases of extreme hardship. They will also consider any other collateral sources of compensation (e.g., workers compensation, life insurance, disability, charitable, and governmental benefits, and other monies paid to the injured patient or any other party) which shall diminish any awards for noneconomic and/or economic damages. The MCP shall be entitled to an off-set for any monies received by the Patient for claims against any other health care provider, if such claims arise out of or relate in any way to the claims of the Patient against the MCP. The parties agree to the complete disclosure of all collateral sources of compensation. Failure to promptly disclose any additional sources on request is agreed to be grounds for immediate and total dismissal of any claim.
Article 4: Merger Clause: This Agreement represents the entire agreement made between the MCP, Provider and the Patient. It supersedes any other agreements between the Patient, Provider and the MCP. Except as expressly set forth herein, there are no other representations, promises, understandings, or agreements of any kind between the parties. The Patient signing this Agreement acknowledges that he or she has not relied in any way upon any oral or written statements made to them besides what is contained within this Agreement. All parties acknowledge and understand that this Agreement cannot be changed, altered or modified in any way except by an instrument in writing, signed by all parties.
Article 5: Pronouns and Headings: The singular shall be held to include the plural, the plural held to include the singular, and the use of any gender shall be held to include every gender. All headings, titles, subtitles, or captions are inserted for convenience only, and are to be ignored in any construction of the provisions hereof.
Article 6: Procedures and Applicable Law: This Agreement, its substantive provisions, the scope of the Agreement, the authority granted to the arbitrators and the limitations contained in this Agreement, are to be governed by, and interpreted pursuant to the Federal Arbitration Act, any conflicting state law notwithstanding. To the extent not inconsistent with the FAA, it shall also be governed by the provisions of the Revised Uniform Arbitration Act.
All arbitration hearings shall be conducted by video conference. Reasonable discovery will be permitted by both sides. The parties agree that the arbitrator is to render a written decision with reasons stated for the decision.
Article 7: Right of Counsel and Rescission: The Patient understands that this Agreement is a legal document, and the Patient has the right to consult with an attorney before signing if desired. You are encouraged you to consult an attorney prior to signing or during a three (3) day rescission period. You may rescind this Agreement for three (3) days after signing it; you agree that it will be in full force and effect until the date received at the by the MCP or Provider. To rescind it, return a copy to the MCP or Provider by certified mail-return receipt only with “CANCELED” written on the first page, and signed by you underneath that word. If timely cancelled, the Agreement will then be rescinded for all future care, but you agree it will be valid for any and all care provided by the MCP or Provider to the Patient for the entire period of all medical services up to the rescission.
Article 8: Authority to Sign: The Patient represents that he or she does have the authority to sign and execute this document on his/her own behalf (if signed by the Patient), or on behalf of the Patient (if signed by a person other than the Patient.)
Article 9: No Undue Influence: The individual signing this Agreement hereby acknowledges that he or she has not been pressured, induced, coerced, or intimidated in any way into signing this agreement, and has signed it of his or her own free will and accord and not under duress of any kind. The parties agree that they have been given every opportunity to ask questions and received answers concerning the specifics and intent of their Agreement.
Article 10: Attorney Fees: The prevailing party shall be entitled to attorney fees and costs incurred in the arbitration process.
Article 11: Mediation: Prior to filing a claim for arbitration, all parties agree to mediate with a licensed Florida Circuit Court Mediator.
NOTICE: BY SIGNING THIS CONTRACT, YOU AGREE TO HAVE ANY ISSUE OF ALLEGED MEDICAL NEGLIGENCE OR BREACH OF CONTRACT BETWEEN YOU AND YOUR MCP DECIDED BY BINDING ARBITRATION IN WHICH BOTH PARTIES GIVE UP THEIR RIGHT TO A TRIAL BY JURY OR TRIAL BY A JUDGE.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information (protected health information) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations.
● Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include crowns, fillings, teeth cleaning services, etc.● Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your dental plan for your dental services.● Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc.
In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services including release of information to friends and family members that are directly involved in your care or who assist in taking care of you. We will use and disclose your protected when we are required to do so by federal, state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that are authorized by law to collect information, to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. We will release your PROTECTED HEALTH INFORMATION if requested by a law enforcement official for any circumstance required by law. We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs. We may release PROTECTED HEALTH INFORMATION to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor. We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. We may disclose your PROTECTED HEALTH INFORMATION if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriateauthorities. We may disclose your PROTECTED HEALTH INFORMATION to federal officials for intelligence and national security activities authorized by law. We may disclose PROTECTED HEALTH INFORMATION to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. We may disclose your PROTECTED HEALTH INFORMATION to correctional institutions or law enforcement HIPAA/@Notice of Privacy Practices.doc officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals or the public. We may release your PROTECTED HEALTH INFORMATION for workers' compensation and similar programs.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below:
● The right to request restrictions on certain uses and disclosures of PROTECTED HEALTH INFORMATION, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
● The right to request to receive confidential communications of PROTECTED HEALTH INFORMATION from us by alternative means or at alternative locations.
● The right to access, inspect and copy your PROTECTED HEALTH INFORMATION.
● The right to request an amendment to your PROTECTED HEALTH INFORMATION.
● The right to receive an accounting of disclosures of PROTECTED HEALTH INFORMATION outside of treatment, payment and health care operations.
● The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your PROTECTED HEALTH INFORMATION and to provide you with notice of our legal duties and privacy practices with respect to PROTECTED HEALTH INFORMATION.
We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.
You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.
For more information about our Privacy Practices, please contact:Vitality Infusions1526 Jackson StreetFort Myers, FL 33901239-935-5292
For more information about HIPAA or to file a complaint:The U.S. Department of Health & Human ServicesOffice of Civil Rights200 Independence Avenue, S.W.Washington, D.C. 202018776966775 (tollfree)
Date of Birth:
Release of Information
This information may be released to:
This Release of Information will remain in effect until terminated by me in writing.
If unable to reach me:
To the Patient:We would like you to have the following information so that you can make an informed decision regarding IV hydration therapy.
What is Intravenous Nutrition Therapy?IV re-hydration/nutritional therapy is a treatment that involves injecting fluids into the veins that vitamins, minerals, amino acids and other nutrients are slowly administered via a small needle into the client's vein.
Benefits included:When nutrients are delivered by IV, the digestive system is bypassed and 100% absorption is achievedat higher and safe concentrations. This allows the nutrients in circulation to be easily obtained by yourcells so your body can heal, repair, function and maintain optimal health.
Proposed Treatment:The area into which the IV catheter needle will be inserted is disinfected. The qualified individual theninserts the needle into a vein in the arm and tapes the needle to the skin to keep it in position. Theinsertion of the needle feels like a mild sting, but the pain quickly subsides.
The amount of fluid entering the vein may be regulated by a manual adjusted valve attached to the tube. A qualified individual will check the site from time to time to be sure the rate of fluids is correct and that the site of the needle on the arm is not leaking or moving. The length of time for the treatment depends on the severity of the dehydration and proposed treatment. We will not diagnose, treat, or cure any specific disease. The purpose of your treatment will be:
Risks and complications:
Risks associated with IV re-hydration are low for most adults. There is a small risk of infectionoccurring at the site of the needle. In most cases, such infections can be treated easily. Another possible risk is creating an imbalance of nutrients in your body if the fluid solution contains the wrong mix of electrolytes. Caregivers should be monitoring to determine if an imbalance or deficiency occurs.
The needle at the insertion site may become dislodged, which can cause a condition called infiltration. This means that the fluids go into the tissues around the vein, rather than into the vein. Infiltration may cause a stinging sensation at the insertion site and a bruise. The needle can be reinserted and a warm compress used to reduce swelling. Keeping still during re-hydration can help prevent dislodging.
Other rare adverse effects from IV therapy include but are not limited to: Allergic reactions to a nutrient, needle, or other supplies used, fever, nausea, upset stomach, and malaise due to changes in blood pressure. As well as the possibility of other unforeseen adverse effects.
I understand that this treatment is strictly voluntary. Therefore, NO SPECIFIC PROMISES ORGUARANTEES OF RESULTS CAN BE MADE for any degree of improvement of my particular condition. There can be NO REFUNDS given for any treatment rendered, regardless of results. I understand that the benefits of IV therapy are much greater if I follow a healthy lifestyle ( non-smoking, weight control, proper exercise, diet and nutritional supplementation.)
I grant permission to Vitality Infusions to take and use: photographs and/or digital images of me for use in news releases and/or educational materials. These materials might include printed or electronic publications, Web sites or other electronic communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of Vitality Infusions. I voluntarily request and authorize the staff of Vitality Infusions to provide my IV infusion treatment.
Frequently Asked Questions About IV Infusion
Why Should I receive IV fluids vs Just drinking Fluids if I am dehydrated?When we become dehydrated, the fluids we lose include water and electrolytes. Drinking water or sports drinks take longer to be absorbed into the body through the GI tract. IV fluids which include electrolytes and other vitamins go directly into your blood stream increasing your body’s fluid volume right away, resulting in you feeling better faster.
Are there any side effects during the IV process?
No major side effects are usually seen; however, people do experience some cooling of the arm and a mineral taste in the mouth. Bruising at the site of injection may occur. Infection at site of infection if sterile technique is not properly used. You may experience rash and dizziness. Do not worry, as this is all normal.
How Long Do Treatments Last?
A typical treatment lasts about 35-55 minutes.
What does a Treatment feel like?
You can expect to feel a small prick like a blood draw and then a slight cooling up your arm. The rest of the treatment you sit comfortably in a reclining chair. There should be no pain associated with treatment.
What will I do during my Treatment?
You can watch our TV with Netflix or bring any device to occupy your time. You can layback in your chair and nap or sit up and work if desired.
How Should I prepare for my Visit?
Wear loose comfortable clothing with easy accessibility to your arms. You will be sitting for about an hour so any clothes should be comfortable.
Can I go about my day after my visit?
Yes. You can resume normal activities the day of your treatment. There are no restrictions to activity.
What information should I share with you prior to my visit?
Any recent medical/surgical issue in the past 6 months. Any complications regarding blood draws or IV’s in the past. Any blood disorders or taking blood thinners should be expressed to us prior to treatment.
Why should I consider add-ons?
Toradol is a nonsteroidal (NSAID) pain reliever that acts quickly to stop pain associated with muscle aches or headaches. Zofran relieves nausea associated with illness, hangover, stomach flu and is a great additive as wellWhat if I normally have trouble getting and IV or blood drawn?
You may not be a good candidate if you have had trouble with IV’s or blood draws in the past. Please notify us of this and our nurses can assess your access points and decide if the service is appropriate. There are occasions where access to a vein is not possible and a refund will be issued if the treatment is not performed
How Often should I get an IV?
Plan around any events that you may have coming up. This would include weekly parties, special occasions, or athletic events. This allows enough time for securing your spot on our schedule. Some people prefer a treatment once a month for the added benefits to your immune system, athletic performance, and/or cosmetic goals. Our most frequent dosage is a bi-weekly program. But you should tailor your IV Therapy to your lifestyle.
Is it an expensive treatment?
IV Therapy is a premium service that improves your body’s performance enormously. It is an investment, so if you compare the price against the benefits you receive from it, you’ll find it’s worth it.
Users agree that preventative medicine such as nutrient IV Therapy strengthens their immune system, helping them avoid expensive doctor visits and prescription medications.
Are all nutrient IV infusions the same?
Not quite. Even though all IV drips are administered using the same procedure the quantities and nutrients on each one are different, since they look to achieve specific goals (skin and hair health, muscle recovery, mental focus, etc.). You can learn more about our IV drip selection on our website.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Vitality Infusions Forms
Agree & Sign