Health History and Consent Form

CONSENT AND ACKNOWLEDGEMENT

Axiom Healthspan In-Person Treatment Consent and Arbitration Agreement

Axiom IV Hydration Therapy, Inc. DBA Axiom Healthspan

Thank you for choosing Axiom Healthspan for your wellness and aesthetic needs. Please carefully read and sign this consent and arbitration agreement, which outlines important information about the services you will receive. By signing this form, you acknowledge and agree to the terms set forth below.

CONSENT TO TREATMENT

1. Scope of Services:

   • I understand that the services provided include intravenous (IV) therapy and/or aesthetic treatments, such as Botox or other botulinum toxin injections. These services are elective and not medically necessary.

2. Acknowledgment of Risks:

   • I understand that all medical and aesthetic treatments carry potential risks and side effects, which may include but are not limited to: discomfort, bruising, swelling, infection, allergic reactions, and, in rare cases, more severe complications.

   • For IV therapy, risks may include infiltration of fluids outside the vein, phlebitis, or infection at the site of injection.

   • For Botox or other botulinum toxin injections, risks may include asymmetry, unintended facial expressions, or temporary weakness in nearby muscles.

3. Voluntary Participation:

   • I acknowledge that I am voluntarily choosing to receive these treatments and have not been coerced or pressured into any procedures.

4. Disclosure of Health Information:

   • I affirm that I have disclosed my full medical history, including any allergies, medications, supplements, and pre-existing health conditions. I understand that withholding information may increase the risk of adverse effects.

5. No Guarantees:

   • I understand that results from IV therapy or aesthetic treatments are not guaranteed and may vary depending on individual factors such as health status, metabolism, and response to treatment.

6. Photography Consent:

   • I consent to photographs being taken before and after my treatment for medical documentation purposes. I understand that these images will be kept confidential unless I provide separate written consent for their use in marketing or educational materials.

FINANCIAL AND CANCELLATION POLICIES

• I understand that payment is due at the time of service.

• I acknowledge that I have received information on the cost of the services and agree to pay for the treatment I receive.

• No refunds will be issued for services rendered.

CONSUMER HEALTH DATA PRIVACY

1. Collection and Use of Health Data:

   • Axiom Healthspan will collect and maintain personal health information (PHI) as part of providing services, including medical history, treatment details, and payment information.

2. Confidentiality and Security:

   • Axiom Healthspan is committed to protecting your health information and ensuring compliance with all applicable privacy laws, including HIPAA.

   • By signing this agreement, you acknowledge and consent to the collection, use, and storage of your health information as outlined in Axiom Healthspan’s privacy policies.

3. Access to Privacy Policies:

   • You can review our full privacy policy, including HIPAA compliance, at https://axiomhealthspan.com/privacy.

   • For additional details on our consumer health data practices, visit https://axiomhealthspan.com/consumer-privacy.

   • The terms of use governing your engagement with Axiom Healthspan can be found at https://axiomhealthspan.com/terms.

4. Access to Records:

   • I have the right to access and request copies of my health records. Requests must be submitted in writing to Axiom Healthspan.

5. Data Retention:

   • My health information will be retained in accordance with state and federal regulations.

ARBITRATION AGREEMENT

1. Agreement to Arbitrate:

   • Any dispute, claim, or controversy arising out of or relating to the services provided by Axiom Healthspan, including claims for personal injury or dissatisfaction with results, shall be resolved by binding arbitration.

   • By signing this agreement, I waive my right to a jury trial or to participate in a class action lawsuit.

2. Arbitration Process:

   • Arbitration shall be conducted in accordance with the rules of the American Arbitration Association (AAA).

   • Each party shall bear its own costs and attorneys' fees unless otherwise ordered by the arbitrator.

3. Governing Law:

   • This agreement shall be governed by the laws of the state in which the services are provided.