IVme, LLC

Patient Consent/Release, Financial Agreement,

Privacy, & Media Authorization Form

This document outlines the terms and conditions of your care at IVme, LLC, located in Athens, Georgia. By signing this form, you acknowledge that you have read, understood, and voluntarily consent to the information contained herein. This form must be completed by each patient or their authorized representative prior to receiving any service.

Consent for Services and Release of Liability

I, the undersigned, voluntarily consent to receive elective wellness services from IVme, LLC and its authorized healthcare providers. I affirm that all information provided in my intake forms, health history, and verbal disclosures is true, complete, and accurate to the best of my knowledge.

Scope of Services

I understand that IVme, LLC provides elective, non-emergency wellness therapies intended to support hydration, nutrient balance, and general wellness. These services may include, but are not limited to:

• IV hydration, vitamin, and medication therapies
• Administration of vitamins, medications, NAD+, peptides, GLP-1 medications, and hormones, provided by IVme, LLC or supplied for self-administration via intravenous (IV), intramuscular (IM), subcutaneous (SubQ), oral (PO), intranasal, or transdermal routes
• Therapeutic phlebotomy
• High-dose Vitamin C and/or Glutathione treatments
• Rapid testing for communicable illnesses such as COVID-19, influenza, streptococcal pharyngitis (strep throat), and mononucleosis (mono)

Nature of Services

I understand and acknowledge that:

• All services provided by IVme, LLC are elective wellness therapies, not required or prescribed medical treatments.
• While IVme’s licensed medical personnel perform vital sign checks, physical assessments, and health screenings to ensure patient safety and eligibility for services, these assessments do not constitute diagnosis or treatment of medical conditions.
• If the IVme, LLC provider’s assessment reveals a potential medical condition or abnormal finding, I may be referred to a primary care provider or appropriate medical facility for further evaluation.
• I am responsible for seeking and maintaining ongoing medical care for any chronic or acute medical conditions.

Risks and Possible Reactions

I understand that while these services are generally considered safe, there are potential risks, side effects, and complications that may occur, including but not limited to:

• Local reactions: pain, redness, swelling, bruising, bleeding, or infection at the injection or IV site
• Systemic reactions: allergic reactions (including anaphylaxis), rash, headache, nausea, vomiting, dizziness, chills, or malaise
• Circulatory reactions: phlebitis (vein irritation), infiltration, or fluid overload
• Neurological reactions: vagal response resulting in dizziness, lightheadedness, fainting (syncope), or near-syncope
• Metabolic effects: electrolyte imbalance, changes in blood pressure, or fluctuations in blood sugar

I acknowledge that severe or unforeseen reactions, including cardiac or respiratory distress, may occur. IVme, LLC staff are trained to respond appropriately, and emergency services (911) will be activated if medically necessary.

Acknowledgment and Release

I acknowledge all services are administered by Georgia-licensed medical providers in good standing, including Paramedics (PMDCs), Registered Nurses (RNs), Nurse Practitioners (NPs), and Physician Assistants (PAs).

Medical oversight for all IVme, LLC services is provided by Medical Director G. Steven Chesser, MD. All IV hydration, vitamin infusions, and medication administrations are performed under his standing protocols and supervision in accordance with Georgia law.

I voluntarily assume full responsibility for any risks or injuries arising from participation in IVme, LLC services. I hereby release, indemnify, and hold harmless IVme, LLC, its owners, officers, employees, medical directors, and contractors from any and all claims, liabilities, or damages arising from my participation in these services, except in cases of gross negligence or willful misconduct.

Financial Responsibility

I understand and agree to the following financial terms:

• All services provided by IVme, LLC are self-pay and elective.
• IVme, LLC does not accept or bill health insurance, Medicare, Medicaid, or any third-party payers.
• I agree to pay in full for all services rendered and products purchased at the time of service.
• I understand that payments are non-refundable, except as otherwise required by Georgia law.
• I acknowledge that I am solely responsible for any and all charges incurred and that IVme, LLC will not submit any claims to insurance on my behalf.

Wireless Communications Policy

IVme, LLC uses telephone, text messaging (SMS), email, and telehealth platforms to communicate with patients regarding scheduling, follow-up, and care coordination.

I acknowledge that:

• While IVme, LLC uses reasonable safeguards to protect my privacy, electronic communications may not be fully secure.
• By providing my contact information, I consent to receive calls, text messages, and emails related to my care, appointments, and services.
• I may opt out of electronic communication at any time by notifying IVme, LLC in writing.
• IVme, LLC complies with the Health Insurance Portability and Accountability Act (HIPAA), the Telephone Consumer Protection Act (TCPA), the Georgia Personal Identity Protection Act, and all other applicable laws governing privacy and communication.

Privacy Practices Acknowledgment

I acknowledge that I have been provided access to IVme, LLC’s Notice of Privacy Practices, which outlines how my Protected Health Information (PHI) may be used and disclosed in accordance with the Health Insurance Portability and Accountability Act (HIPAA), O.C.G.A. § 31-33 (Georgia Medical Records Act), and all other applicable state and federal laws. I understand that I may request a copy of this Notice at any time by contacting IVme, LLC at (706) 296-7114 or by email at info@ivmemobile.net.

I understand that:

• My PHI may be used for treatment, payment, and healthcare operations.
• I have the right to request restrictions or amendments to my medical record, and to obtain copies of my records consistent with Georgia law.
• I may file a complaint regarding privacy concerns without fear of retaliation.

Media and Photo Consent

I authorize IVme, LLC to take photographs, videos, or other media recordings of me in connection with my treatments or participation in clinic activities.

I understand that:

• Such materials may be used for marketing, social media, educational, or promotional purposes.
• IVme, LLC will always request verbal consent before capturing any media.
• My identifying information will not be shared without additional written consent.
• I may revoke this consent in writing at any time, but revocation will not apply to materials already published.

Georgia Law Compliance Notice

IVme, LLC operates in compliance with the Georgia Composite Medical Board and all applicable rules and regulations governing medical practice and delegated healthcare services within the State of Georgia.
Patient records and information are maintained in accordance with the Official Code of Georgia Annotated (O.C.G.A.) § 31-33, which governs patient access to and confidentiality of medical records.

Acknowledgment and Signature

By signing, I affirm that:

• I have read and understand the information provided above.
• I have had the opportunity to ask questions and have received satisfactory answers.
• I voluntarily consent to receive elective wellness services from IVme, LLC under these terms.
• I understand that IVme, LLC does not diagnose or treat medical conditions and that I am responsible for maintaining my own medical care.
• I agree to pay in full for all services rendered and products purchased.