IV HYDRATION ORDER FORM
Re-hydrate. Restore. Revitalize.
BASED IN LUBBOCK, TEXAS
WITH THE BEST MEDICAL PROFESSIONALS HERE AT LONE STAR MOBILE MED, WE ARE CHANGING WELLNESS IN THE COMFORT OF YOUR HOME. IF YOU ARE EXPERIENCING JET LAG, MIGRAINES, RECOVERING FROM TOUGH WORKOUTS, MANAGING STRESS, OR SIMPLY LOOKING TO BOOST YOUR WELLNESS, YOU’VE COME TO THE RIGHT PLACE.
WE PROVIDE MANY IV HYDRATION PACKAGES TO CHOOSE FROM. WE OFFER RELIEF WITH HIGH QUALITY, COST-EFFICIENT, MEDICAL HYDRATION DELIVERED INTRAVENOUSLY. ALL OF OUR PACKAGES ARE DOCTOR-RECOMMENDED AND SAFE.
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I understand that participating in intravenous (IV) hydration, vitamin / supplement administration programs and services carries risks.
I ACKNOWLEDGE and AGREE that the sole risk of injury or harm resulting in any manner from choosing to participate in such treatment programs rests entirely with me to the extent that I do not disclose my health conditions, medications, or drug use in advance.
I expressly represent and warrant to LoneStar Mobile Med (LSMM) that I have never been diagnosed with nor tested for any diseases, illnesses, or conditions which may result in increased risk when I participate in Hydration therapy provided to me by LSMM, and that I have no expectation that LSMM will screen for, diagnose, monitor, or otherwise provide any care or treatment for such conditions.
Certain risks and hazards have been explained to me PRIOR to my consent for IV Hydration including, but not limited to :
- Injury , Bleeding , Infection, Inflammation, Swelling, Bruising, Scarring resulting from IV infiltration, Extraction, and Extravasation
- Misplacement of IV lines
- Fluid overload
- Adverse reaction to medications
I confirm that I have read this form and fully understand it’s contents. I acknowledge that no guarantees or assurances have been made to me concerning Hydration therapy. I have been given the opportunity to ask questions. I agree to my assumption of all risks associated with my participation.