TERMS & CONDITIONS
TERMS AND CONDITIONS OF BEYOND NURSE, LLC T/A FACE IT BY DR G
I, the undersigned participant, understand that participating in the following activities: intravenous (“IV”) hydration, vitamin/supplement administration, pharmaceutical administration, other programs and services related to intravenous administration made available by Beyond Nurse LLC DBA Face It! By Dr. G carries risks. The Service is only available to individuals who are at least 13 years old. If you are not 13 years old, please do not use our Service.
Exculpatory Clause: I affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with the activities I have chosen. The risks include, but are not limited to, injury, bleeding, infection, inflammation/swelling, bruising or scarring from IV infiltration, extraction and extravasation, misplacement of IV lines in the body, air embolism, fluid overload, medication adverse interactions, nerve injuries, lightheadedness or fainting. I fully understand that these risks can lead to personal injury, illness, permanent disability, death or damages to me. To the extent that I fail to disclose any of my health conditions, medications or drug use in advance, I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such regiment, programs, and services rests entirely with me. Despite the potential hazards and dangers associated with the activities, I voluntary agree to participate in the activities and hereby accept and assume all such risks, known and unknown, and assume all responsibilities for the losses, costs, and/or damages following such personal injury, illness, permanent disability, death or damages to me, even if caused in whole or in part, by the negligence of Face It! By Dr. G officers, directors, volunteers, agents, servants, or employees.
I expressly represent to Face It! By Dr. G truthfully, my past medical history; I acknowledge and understand that Face It! By Dr. G is relying upon the foregoing representations that I am providing to Face It! By Dr. G in choosing to accept me for participation in its program(s) or service(s). I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by Face It! By Dr. G and that Face It! By Dr. G reserves the right to decline me treatment based on the clinical evaluation made by the nurse or nurse practitioner.
I consent to receiving a medical screening via telehealth/telemedicine methods and understand that there are certain risks associated with receiving care through telehealth/telemedicine methods. Furthermore, I have made the medical staff aware of all my known health conditions, allergies, and medications I am taking.
I expressly represent and guarantee to Face It! By Dr. G that I am not a user of illegal drugs or controlled substances, and I am not under the influence of or recovering from any drugs or controlled substances at the time of any service provided to me by Face It! By Dr. G. In the event of an emergency, I will be sure to call 911 or proceed to the nearest emergency room.
Release and Waiver: I acknowledge that Face It! By Dr. G has made no warranties or guarantees as to the results or general success of the IV, vitamin/supplement administration, pharmaceutical administration, programs or any other intravenous programs and services made available by Face It! By Dr. G and all expressions made by Face It! By Dr. G relative thereto, are opinions that should not be relied upon. By entering into this agreement, I am not relying on any oral or written representation or statement made by Face it By Dr. G or any of its officers, directors, agents, employees, volunteers, or representatives other than what is set forth in this agreement.
I waive and release any and all claims based upon negligence, active or passive, with the exception of intentional, wanton, or wilful misconduct that I may have in the future against Face It by Dr. G and its officers, directors, agents, employees, volunteers and representatives which are in any way associated with the services.
I release Face It! By Dr. G and its officers, directors, agents, employees, volunteers and representatives from liability and responsibility, whatsoever, for any claim of action that I, my estate, heirs, executors or assigns may have for any personal injury, property damage, or wrongful death arising from the service whether caused by active or passive negligence of Face It! By Dr. G or any of its officers, directors, agents, employees, volunteers or representatives with the exception of gross negligence. By executing this document, I agree to hold Face It! By Dr. G and its officers, directors, agents, employees, volunteers and representatives harmless for any personal injury, illness, permanent disability, or death which may occur to me, or for any damage to my property, during the service.
Indemnity Clause: I acknowledge that ancillary damages may occur to my property as a result of participating in IV hydration, vitamin/supplement administration, pharmaceutical administration, or any program/service made available by Face It! By Dr. G. I agree to indemnify and hold harmless Face it By Dr. G and its officers, directors, agents, employees, volunteers and representatives for any and all claims arising out of or resulting from, or alleged to have arisen out of or resulting from my engaging in or participating in the activities, services and programs offered by Face It! By Dr. G.
I understand that this waiver is intended to be as broad and inclusive as permitted by the laws of Maryland and agree that if any provision of this agreement is found to be unenforceable or invalid, that provision shall be severed from this agreement. The remainder of this agreement will then be construed as though the unenforceable provision had never been contained in this document.
Blind heirs: This agreement shall be binding upon my heirs, personal representatives, successors and assigns.
Insurance and FDA Approval: I understand that Face it By Dr. G does not carry or maintain health, medical or disability insurance coverage for any participant. Each participant is encouraged and expected to obtain their own medical and health insurance coverage.
I acknowledge that IV hydration services provided have not been evaluated by the United States Food and Drug Administration and IV hydration is not intended to diagnose, treat, cure of prevent any disease.
Credit/Debit Card Authorization: By signing this form, I authorize I Face It! By Dr. G to debit my credit card provided for any product/service rendered and understand the authorization to be valid. I accept full and complete financial responsibility for all medical services rendered to me and agree to pay for the services in full upon receiving services. I further acknowledge, understand, and agree that in the event that I fail to make such payments in accordance with the payment policies of Face It! By Dr. G, or in the event of default of my financial obligation to pay for services rendered, Face It! By Dr. G may terminate the “provider-client” relationship with me. Furthermore, in the event of my default of my financial obligation, should my account be turned over to an external collection agency for non-payment, I agree to pay any associated collection costs.
Voluntary Signature and Acknowledgement: I confirm that I have fully read this form and fully understand the contents of this agreement. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction. I have consulted and relied upon my own advisors on all questions in connection therewith.
I consent to the above terms:
Print:________________ Sign:________________ Date:________________