Revived Body - Mobile IV Therapy & Aesthetics
Vitamin Therapy - Weight Loss Injections Waiver

All new clients must complete this waiver before receiving an IV/ IM/ subQ vitamin or medication from Revived Body

Client Intake

Please fill out the following form in order to participate in our services.

Name

Birthday

Age

Gender

Male

Female

Rather not say

Address

Emergency Contact Name

State and ZIP code

Phone

Emergency Contact Phone

Have you had IV Infusion or Injections in the past?

IV Infusion

Vitamin Injections

Weight Loss Injections

None of Above

Allergies (Medications, food, etc)

Current Medications (include OTC and supplements):

Please check any conditions that apply to you:

Other condition/s

WOMEN (non menopausal)

Are you currently breastfeeding?

Yes

Any chance of pregnancy?

Yes

I attest that the information I have provided is true and accurate to the best of my knowledge:

Client Consent

This form outlines that you understand that a peripheral intravenous catheter will be inserted into a vein in your body, and you will have fluids, vitamins, minerals, nutrients, and/or medications infused directly into your body. This is considered “IV Infusion Therapy.” If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.”

By reading the following statements carefully and signing below, I acknowledge that:

I understand that IV infusion and injection therapy at REVIVED BODY LLC is not intended to diagnose or treat a specific medical condition.

I understand that IV infusion and injection therapy will not prevent, treat, or cure any medical condition or disease. Furthermore, I understand that I am here seeking IV infusion and/or injection therapy voluntarily to assist with certain symptoms or ailments I may be experiencing.

I have informed REVIVED BODY LLC of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.

I understand that IV and injectable therapy and any claims made about these treatments have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. I understand that these treatments are not FDA approved for any given indications of treatment and are not considered a medical necessity.

I understand that I have been informed of the procedure involving IV infusion and injections, the alternative treatment options, and the risks and benefits of the mutually agreed upon treatment.

I understand that the procedure involves inserting a needle into a vein or having a solution injected into my muscle or body fat.

I understand that common risks involved with IV and injection therapies include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the IV insertion or injection.

I understand that less common risks involved with IV and injection therapies include, but are not limited to, infection at the site of the IV insertion or injection, injury to the tissue, phlebitis, low blood pressure, fainting, fluid volume overload, medication interactions, and drops in blood sugar levels.

I understand that rare side risks involved with IV and injection therapies include, but are not limited to, sepsis, severe allergic reactions, severe medication/supplement interactions, anaphylaxis, blood clots, shock, cardiac arrest, and death.

I understand that the benefits of IV and injection therapies include, but are not limited to, enhanced absorption of vitamins and minerals as they bypass the digestive tract, increased total body hydration, alleviation of certain symptoms, increased total body nutrient density, and improved performance/recovery.

I affirm that I am voluntarily seeking IV infusion and injection therapies at REVIVED BODY LLC and have not been coerced into doing so.

I understand the risks and benefits of the procedure, IV infusion therapy, and injection therapy and have had all my questions answered to my full satisfaction.

I understand that unforeseeable complications can arise when an IV is placed and medications/fluids/minerals/vitamins are infused into the body.

I understand that I have the right to refuse any treatments or treatment recommendations at any time.

Patient Acknowledgements and Consent Regarding Weight Loss:

I understand that the purpose of these weight loss injections is to assist in weight management and should be combined with a healthy diet and regular exercise.
I acknowledge that the results of weight loss injections can vary from person to person and that they may not lead to guaranteed weight loss.
I have received information about the potential benefits, risks, and side effects associated with these injections and have had the opportunity to ask questions. My questions have been answered to my satisfaction.
I understand that the weight loss achieved with these injections may not be permanent, and I may regain weight after discontinuing the medication. It is important to be aware that weight maintenance often requires ongoing lifestyle changes, including a balanced diet and regular physical activity.
I understand that potential side effects may include but are not limited to: local injection site reactions, mild headaches, nausea, and rare but more serious complications.

Non-Refund Policy

I acknowledge and understand that all fees paid for medication (including IV, IM, or SubQ injections), weight loss services, or any other services provided by Revived Body are non-refundable. Once payment has been made, there will be no refunds or reimbursements, regardless of the outcome or my decision to discontinue the treatment. I consent to this non-refund policy and agree to abide by it.

Voluntary Nature of Treatment and Alternative Therapies

Treatment with IV and injectable vitamins/hydration/nutritional/mineral and/or medications offered at REVIVED BODY LLC is completely voluntary in nature. Alternative therapy for the symptoms you are seeking IV infusion and injectable therapy for include, not are not limited to, ongoing treatment by your primary care provider and/or specialty provider, oral supplementation, and dietary/lifestyle modifications.

I acknowledge that IV infusion and injection therapy provided at REVIVED BODY LLC is voluntary in nature and that I am seeking out this therapy on my own or from the recommendation of my referring provider. I acknowledge that I have also notified my medical and/or mental health provider about my decision to undergo IV and injectable vitamin/hydration/nutritional/mineral therapy. I acknowledge the alternative treatment options and have voluntarily decided to pursue IV and injectable therapy.

I have carefully read the above and understand the contents and thus sign this as my own

Your Signature

Print Name

Select a date

Revived Body - Mobile IV Therapy & Aesthetics Vitamin Therapy - Weight Loss Injections Waiver

All new clients must complete this waiver before receiving an IV/ IM/ subQ vitamin or medication from Revived Body

Client Intake

Please fill out the following form in order to participate in our services.

Client Consent

By reading the following statements carefully and signing below, I acknowledge that:

Patient Acknowledgements and Consent Regarding Weight Loss:

I understand that the purpose of these weight loss injections is to assist in weight management and should be combined with a healthy diet and regular exercise.

I acknowledge that the results of weight loss injections can vary from person to person and that they may not lead to guaranteed weight loss.

I have received information about the potential benefits, risks, and side effects associated with these injections and have had the opportunity to ask questions. My questions have been answered to my satisfaction.

I understand that the weight loss achieved with these injections may not be permanent, and I may regain weight after discontinuing the medication. It is important to be aware that weight maintenance often requires ongoing lifestyle changes, including a balanced diet and regular physical activity.

I understand that potential side effects may include but are not limited to: local injection site reactions, mild headaches, nausea, and rare but more serious complications.

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Non-Refund Policy

Voluntary Nature of Treatment and Alternative Therapies

Revived Body - Mobile IV Therapy & Aesthetics
Vitamin Therapy - Weight Loss Injections Waiver