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Consent Forms


At Miami VIIV, we take our clients' health and safety seriously. That's why we require all clients to fill out our medical waiver form before they can participate in any of our services. Our medical waiver form outlines any risks associated with our services and allows us to tailor our services to your specific needs. By filling out this form, you are helping us to ensure that you are receiving the best possible care and that you are aware of any potential risks involved. We thank you for taking the time to complete this important form.

General Release of Liability

I, (signer of this form listed below), on this day (current date listed below) intending to be legally bound hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless MIAMI VIIV LLC and employees or agents representing or related in regards to my health, my results, any other accident, or unexpected outcome.

This release is for any or all liability for personal injuries (including death) property losses or damages occasioned by or in connection with the person or entity being released.  
The undersigned fully agrees to abide by all the rules and instructions given by MIAMI VIIV LLC, and its affiliate groups and vendors.

Thanks for submitting!

General Release of Liability

Medical Questionnaire

Patient Information


Medical Questionnaire For IV/IM/SUBQ Therapy: In order for us to serve you better. Please answer the following: Check Yes or No: If YES to any question, please explain. Have you now or had in the past?
 

1. Valvular Heart Disease / Heart Surgery?
4. Heart Attack / Stroke?
7. Condition of Sodium Retention or Electrolyte Imbalance?
10. Severe Frequent Headaches?
13. History of Stomach Ulcers?
16. Do you have Sulfa Allergies?
19. Do you have any thyroid conditions? (e.g. Hyper/Hypothyroidism, ect.)
2. Severe Renal Impairment? (e.g. Kidney Failure, Dialysis)
5. History of Bleeding or Platelet Problems?
8. Edema or Water Retention?
11. Fainting / Seizures / Epilepsy?
14. Any liver conditions? (e.g. Liver Cirrhosis, Liver Disease)
17. Do you have or have had asthma?
20. Are You currenty taking any prescribed and/or over the counter medications? (e.g. vitamins, Tylenol, ect.)
3. Congestive Heart Failure?
6. Do you take any Blood Thinners (including Plavix, Coumadin/Warfarin, Xarelto, Eliquis, or Pradaxa)?
9. High / Low Blood Pressure?
12. Diabetes / Low Blood Sugar?
15. Any allergies? If yes, please list below (Allergies Section)
18. Do you have any medical history? Please list below (Medical History Section)
21. *Females Only: Are You Pregnant?

Thanks for submitting!

Medical Questionnaire

Terms, Conditions & Consent for IV Hydration Therapy 

At MIAMI VIIV LLC, we provide IV (intravenous), IM (intramuscular) and SUBQ (Subcutaneous) injection therapies. These treatments include administration of some combination of IV fluids (Normal Saline or Lactated Ringer’s), anti-oxidants, vitamins and minerals, amino acids, electrolytes, compounded cofactor, and/or medications.

Our hydration therapy is specifically designed to counteract symptoms of dehydration, fatigue, and the residual effects of nutrients and H2O depletion. We offer no diagnostic testing, make no medical diagnoses, and reserve the right to refuse treatment to any patients we deem are intoxicated unstable, or whose symptoms are not consistent with the above. The vast majority of our clients receiving our therapy feel greatly improved; however, every individual is different and there is no guarantee that you will feel better after an infusion; nor does your improvement of symptoms exclude other coexisting potential medical conditions. This document is designed to serve as confirmation of informed consent for IV therapy as suggested by the qualified staff present on site.

I have informed the staff of any known allergies to drugs, other substances, and medical conditions or of any past reactions to medications or anesthetics. I have informed the staff of all current medications and supplements I am taking. 

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and give my concerns.

I understand the benefits of IV infusions, IM and SUBQ injections may be limited if I am an active smoker, live a sedentary lifestyle, have certain medical conditions and/or have a diet that contains an excess of calories and/or a deficiency of nutrients. I understand that I may be asked to take oral supplements between treatments and a failure to take these supplements may reduce the benefits of the IV/IM/SUBQ therapy and may even create unwanted effects of the IV/IM/SUBQ therapy.

I understand that a series of infusions and/or injections may be anticipated. I understand that infusion(s) and/or injections may need to be repeated in the future in order to maintain the benefits.

I acknowledge that I am aware of the risks inherent in peripheral vascular catheterization and IV infusion, IM/SUBQ medication and compound injection that include but are not limited to: local irritation, pain, infection, phlebitis (irritation of the vein), venous thrombosis, shortness of breath, allergic reaction, fluid volume overload, medication interactions, and death. Despite these risks (and others) I consent to the procedure.

Payment:

Payment is due at the time of service. There has been no representation that this procedure is covered under my insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless of if the infusion cancelled or is stopped at any time prior to completion at the discretion of the technician/nurse/clinical assistant or myself.

I understand that I am responsible for the full cost of the procedure and agree to pay.

The procedure(s) and this consent form have been adequately explained to me.

I certify that I am not Allergic to any medication, vitamins, minerals or any other compound.

I understand that I have read and understand the above. I am at least 18 years of age, or am accompanied by a parent or guardian. I have provided complete and accurate medical screening information above, to the best of my knowledge. I attest I am not under the influence of alcohol or any other mind-altering substances.

I understand that:

  • The procedure involves inserting a needle into a vein, intramuscular and/or subcutaneous tissue and injecting the selected solution/medication/compound.

  • Risks of intravenous, intramuscular or subcutaneous therapy include, but are not limited to: discomfort, bruising, and pain at the site of injection. 

  • Other rare but possible side effects include but are not limited to: inflammation of the vein/area used for injection, phlebitis, metabolic disturbances, and injury. 

  • Nutrients are forced into the cells by means of a high concentration ingredient. 

  • I understand the information provided on this form and agree to the foregoing. 

  • I have received all the information and explanation I desire concerning the procedure. 

  • I authorize and consent to the performance of the procedures(s). 

Lastly, I hereby hold MIAMI VIIV LLC and any affiliated members free and harmless from any claim of damage that might arise in the process of providing medical care to myself or other designee. My signature indicates that I have read this document in its entirety and accept services with full knowledge. 

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