Client Consent for TreatmentI understand that I am submitting a digital form that will not be shared outside of Luxurious IV Therapy. PATIENT INFORMATION Name * First Name Last Name Date of Birth * MM DD YYYY Age * Gender * Male Female Non-Binary Other Phone (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Relationship * Referral How did you hear about us? Advertisement Referral Social Media Friend Other Client Referral First Name Last Name Consent * Agreement and Consent for Treatment: It is understood by both parties that I named above, authorize and Direct Luxurious IV Therapy LLC and its associates/employees to perform procedures that, in their judgment, are considered advisable or necessary for the patient whose name appears above. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained, and the nature, purpose, and risks of the procedures and possibilities of complications have been explained to me. It is understood and agreed that any claim or dispute in connection with treatment involving Luxurious IV Therapy LLC and its associates/employees participating in my examination or care shall be settled under Luxurious IV therapy LLC professional insurance. Any personal accident or injury that may occur on the premises shall be settled with Luxurious IV Therapy LLC General & Property Insurance and no claim shall be brought against the Providers, associates, or employees of the program. By signing your name below you are electronically agreeing to the terms above, on the day/time the form is submitted. First Name Last Name Thank you!
