Miami VIP Hydration

Patient Intake

Medical Consent Form

Please complete this form before your first appointment. All information is kept confidential in accordance with HIPAA.

Patient Information

Health Questionnaire

Please check all that apply

Informed Consent

Consent to Treatment

I voluntarily consent to receive intravenous (IV) hydration and vitamin infusion therapy administered by a licensed Registered Nurse under the standing order and supervision of the Medical Director of Miami VIP Hydration, LLC. I understand my clinician will perform an assessment prior to treatment and may decline to administer therapy if it is not clinically appropriate.

Acknowledgment of Risks

I acknowledge that IV therapy carries risks including but not limited to: bruising, bleeding, infiltration, phlebitis, infection, vein irritation, lightheadedness, allergic reaction, and, rarely, more serious reactions. I have had the opportunity to ask questions and understand no specific outcome has been guaranteed. Services provided are wellness services and are not intended to diagnose, treat, cure, or prevent any disease.

HIPAA / Privacy Notice

I acknowledge that my protected health information (PHI) will be used and disclosed only for treatment, payment, and health care operations as permitted by the Health Insurance Portability and Accountability Act (HIPAA). I have been offered a copy of the Notice of Privacy Practices upon request.

Financial Responsibility

I understand Miami VIP Hydration does not bill insurance. Payment is due at the time of service. I authorize charges to the payment method on file for services rendered, applicable taxes, and any additional add-ons requested during my visit. Cancellations within 2 hours of the appointment may be subject to a service fee.

Telehealth & Standing Orders

I consent to evaluation and treatment authorization by the Medical Director via telehealth and/or standing orders as permitted by Florida law. I understand I may withdraw this consent at any time by notifying the clinician on site.

Electronic Signature

By signing below I certify the information provided is accurate to the best of my knowledge and I am the patient (or the patient's legal guardian). My electronic signature has the same legal effect as a handwritten signature (E-SIGN Act, 15 U.S.C. § 7001).

Signed on July 22, 2026

Miami VIP Hydration, LLC · Medical Director on File · State of Florida