Prior to receiving treatment, I affirm that I have been honest in providing BioMed Mobile IV with my accurate medical history and current medications, including over the counter medications. I acknowledge that omissions about my medical condition and or medications could result in a negative outcome.

Contraindications for receiving IV hydration are altered mental status, congestive heart failure, chronic kidney disease, altered mental status, acute kidney injury (AKI) with GFR <30, uncontrolled hypertension or any hypertensive patient that is symptomatic with chest pain, vision changes or headache, clotting disorders, Graves' disease, Leber's hereditary optic neuropathy (LHON), pregnancy with preeclampsia or a history of preeclampsia in a previous pregnancy, pregnancy with diagnosis of gestational diabetes and pregnancy >32 weeks.

Patients on Hospice are excluded from the list of contraindications.

It has been noted that in rare instances IV hydration has resulted in the following:

• Irregular heartbeat (preexisting cardiac arrythmia condition)

• Light-headedness

• Muscle cramps

• Inflammation of a vein (phlebitis) after the infusion

There is a possibility that some minor discomfort, redness, bruising, and or bleeding at the injections site may occur and usually revolves in a minimal amount of time.

I will remove the self-adherent wrap within 30 minutes of a application.

I am aware that receiving IV hydration is not considered definitive care for any acute or chronic medical illness and that neither BioMed Mobile IV nor its contractors have made any such claim.

Should any of my symptoms persist or worsen I will seek medical attention from my primary care provider.

I am aware of possible side effects and contraindications.

The undersigned does hereby completely and fully release and discharge BioMed Mobile IV of any obligation , liability and/or responsibility for any complications arising from this IV treatment.

I have read and fully understand the terms within the above consent, and my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, and if I do not, I have appointed someone to translate this consent form in its entirety.