VITALICE bears no responsibility for any financial consequences that may arise after or during the administration of the IV therapy drip treatment.
VITALICE provides facilities and personnel to assist in the performance of intravenous therapy. You have the right to be informed of the procedure, any feasible alternative options, the risks and benefits. Alternatives to intravenous therapy is oral supplementation and/or dietary and lifestyle changes. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent. VITALICE does not claim any clinical therapeutic outcomes, and results may vary from every individual patient.
The procedure involves inserting a needle into your vein or muscle and injecting the formula prescribed by your physician. It will be performed by or under the direction of your physician with qualified healthcare providers.
Benefits of intravenous therapy include:
- Injectable are not affected by stomach or intestinal disease.
- Total amount of infusion is available to the tissues.
- Nutrients are focused into cells by means of a high concentration gradient.
- Higher doses of nutrients can be given than possible by mouth, without intestinal irritation.
Risks of intravenous therapy include:
- Potential risks of pain, discomfort, bruising, infection, or inflammation of the vein/phlebitis at or near the injection site.
- Severe allergic reaction.
Serious potential side effects could occur in the following patients:
- A genetic defect called “Glucose-6-Phosphate Dehydrogenase Deficiency”, or G6PD--deficiency, also known as “Favism”
- Patients with Chronic Renal Insufficiency, or decreased kidney function
- Patients with Congestive Heart Failure and/or Atrial Fibrillation “A--fib”
- Patients with very Low Blood Pressure, readings lower than 90 mm Hg systolic or 60 mm Hg diastolic (esp.
Magnesium containing IV Infusions)
- Patients taking Digoxin or other Potassium--depleting drugs, diuretics, beta-agonists, or glucocorticoids; If patient is hypokalemic (esp. Magnesium containing IV Infusions)
- Unknown allergies
Pregnant women:
You have the right to consent to or refuse any proposed treatment at any time prior to its performance.
Your signature AFFIRMS that:
- You understand the information provided on this form and agree to the foregoing.
- The procedure(s) set forth above has been adequately explained to you by your physician.
- You have received all the information and explanation you desire concerning the procedure.
- You authorize and consent to the performance of the procedure(s).
A. Release and Waiver. To the extent allowed by applicable law, I for myself (and also for my child participant, if applicable), agree as follows: to release and not to sue HYROX, Event
sponsors, Event organizers, Event promoters, Event producers, race directors/judges, Event officials, Event staff, advertisers, administrators, contractors, vendors, volunteers, and all
property owners and state, city, town, county, and other governmental bodies, and/or municipal agencies whose property and/or personnel are used and/or in any way assist in locations
where the Activities take place, and each of their respective parent, subsidiary and affiliated companies, assignees, licensees, owners, officers, directors, partners, board members,
shareholders, members, supervisors, insurers, agents, employees, volunteers, contractors and representatives and all other persons or entities associated or involved with the Activities
(the "Released Parties"), with respect to any and all Claims, liabilities, suits or expenses (including attorneys’ fees and costs) (the “Claim” or “Claim(s)”) that I may have, for any injury,
damage, death or other loss in any way connected with my enrollment or participation in and/or assistance with the Activities, including use of and/or assistance with any equipment,
facilities or premises (and losses resulting from the inherent or other Risks of the Activities). I understand I agree here to waive all Claim(s) I may have against the Released Parties and
agree that neither I, nor anyone acting on my behalf, will make a Claim against the Released Parties for any loss I may suffer, if I suffer injury, damage, death or other loss; to defend and
Indemnify (“Indemnify” meaning protect by reimbursement or payment) the Released Parties with respect to any and all Claim(s) brought by or on behalf of me, (my participating child) or
other family member/s, a co-participant or any other person, for any injury, damage, death, lost and/or stolen property or other loss in any way connected with my, or my child’s, enrollment
or participation in and/or assistance with the Activities, including use of and/or assistance with any equipment, facilities or premises (and losses resulting from the inherent or other risks of
the Activities).
B. Claim(s) Included. This Release and Indemnity section includes Claim(s) resulting from any of the Released Parties’ negligence (but not any of their intentional misconduct), and includes
Claim(s) for personal injury or wrongful death (including Claim(s) related to emergency, medical, drug and/or health issues, response, assessment or treatment), property damage, loss of
consortium, breach of contract or any other Claim.
C. Minor Participant. If the participant is a minor, I (the minor participant’s parent) for and on behalf of my participating minor child, agree as follows: I agree to waive and release, in
advance, any Claim(s) or cause of action against the Released Parties that would accrue to my minor child for personal injury, including death, and property damage resulting from an
inherent risk in the Activity.
