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Terms & Conditions
Liability Waiver

Informed Consent for IV and IM Vitamins, Micronutrient and Chelation Therapy

I, as a patient, have a right to be informed about my condition or recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent as to whether or not to undergo care having had the opportunity to discuss potential benefits, risks, and hazards involved.

Benefits:

-Increased Energy

-Hydration

-Increase in Metabolism

-Cardiovascular Support

-Support Nail, Skin, and Hair

-Immune Support

-Many Other Benefits

Risks and Hazards:

-Reaction to Vitamins- Fever, rash, hives, wheezing and joint swelling are some allergic reactions you could experience during IV therapy.

-Bleeding or Bruising of Area

-Infection of Venipuncture Site

-Other minor complications are sometimes associated with IV Therapy

I hereby request and voluntarily consent to examination and treatment with IV therapies with vitamins, micronutrients, chelation, detoxification, nutrition and placement of IV catheters or IM injection of Vitamins by Dr. Paul Y. Song and/or other licensed employees working for Drip IV Therapy + Mobile under the guidance of Dr. Song. I can request further explanation of the procedure or methods of treatment, and information about the material risk of the procedure or treatment.

I understand that the US FDA has not evaluated or approved nutritional, or herbal treatment specifically or may recommend different treatments. However, they have been widely used in Europe and the USA for years. I understand as with drugs, nutritional supplements (i.e. vitamins, trace elements, antioxidants, etc.) may exhibit some side effects in certain individuals, who may interact with certain allopathic medications. I do not expect the doctor or staff member to anticipate and explain all risks and complications, and I wish to rely on the medical professional to exercise judgment in the recommendation in the procedure at the time. I have had the opportunity to ask all questions and discuss with my healthcare provider(s) to my satisfaction:

-My suspected diagnosis or condition

-The nature, purpose and potential benefit of the proposed care

-The inherited risks, complications, potential hazards, or side effects of the proposed

-Reasonably available alternatives to the proposed treatment/procedure

-The possible consequences if treatment advice is not followed

I understand that in the practice of IV therapy there are some risks of examination and treatment and that the following possible complications could occur, although they are very unlikely: irritation at the site of the IV insertion or the vein itself, infection, bleeding, allergic reaction to the infused vitamins, minerals or compounds including anaphylaxis, fever, nausea, upset stomach, arrhythmias, and other unlikely and possible reactions.

ARBITRATION AGREEMENT


The undersigned (“You” or “Your”) hereby consents to voluntarily agree to submit any disputes with PKSD Holdings L.L.C, dba Drip IV Therapy + Mobile. You agree that any and all controversies, claims or disputes arising out of, relating to or concerning any interpretation, construction, performance or breach of the service provided. You and Company entered into as of 07/28/2018 (the “Agreement”) shall be subject to binding arbitration to be held in the County of Los Angeles, CA, in accordance with the then-current rules of the American Arbitration Association (“AAA”) for the resolution of Medical Procedures type of disputes (the “Rules”). You further consent that any arbitration will be administered by the AAA and that the arbitrator shall be selected in a manner consistent with the Rules. To initiate the arbitration process, the aggrieved party must file and serve upon the responding party a written claim in accordance with the Rules. You also agree that the arbitrator shall have the power to award any remedies, including preliminary relief, injunctive relief, attorneys fees, and costs and all other remedies available under applicable law. The decision of the arbitrator shall be final, conclusive and binding on the parties to the arbitration. Judgment may be entered on the arbitrator’s decision in any court having jurisdiction. This is the complete agreement of the parties on the subject of arbitration of disputes, except for an arbitration provision contained in any pension or benefit plan. You acknowledge and agree that You are executing this Agreement voluntarily and without any duress or undue influence by Company or anyone else.