Health History & Consent.

Health History and Consent

AXIOM IV HYDRATION THERAPY, INC. DBA AXIOM HEALTHSPAN
COMPREHENSIVE CONSENT FORM AND ARBITRATION AGREEMENT

This agreement applies to all services provided by Axiom IV Hydration Therapy, Inc. DBA Axiom Healthspan ("Axiom Healthspan"), including aesthetic treatments, IV hydration therapy, longevity medications, weight loss programs, and peptide/regenerative therapies. By signing this agreement, I acknowledge and consent to the terms, conditions, and potential risks associated with these services.

1. Acknowledgment of Services

I understand that I am receiving one or more of the following services from Axiom Healthspan:

• Aesthetic Treatments: Botox, Juvederm, Versa, Dysport, or other injectable treatments.

• IV Hydration Therapy: Administration of fluids, vitamins, minerals, and/or medications via intravenous, intramuscular, or subcutaneous routes.

• Longevity Medications: Including NAD+ nasal spray and cream, hair restoration treatments, GHK-Cu scalp and facial solutions, and Sildenafil.

• Weight Loss Medications: Including Semaglutide, Tirzepatide, Bella Capsules, and Lipo B.

• Peptide and Regenerative Therapies: Including, but not limited to, BPC-157, CJC-1295, Ipamorelin, PT-141, or other regenerative products designated for Provider Use Only.

Provider Use Acknowledgment: I acknowledge that I am obtaining peptides or regenerative products strictly under the direction of my licensed provider. I understand these products are designated for Provider Use Only and are not FDA-approved for the diagnosis, treatment, or cure of any disease. These products are intended solely for provider-directed application and not for resale, personal purchase, or unsupervised administration.

I confirm that I have disclosed all known allergies, medical conditions, medications (including over-the-counter and recreational drugs), and supplements to the medical provider. I affirm that I am not pregnant, breastfeeding, or immunocompromised. I acknowledge that failure to provide accurate information may increase the risk of complications, and Axiom Healthspan is not liable for any such complications arising from incomplete or inaccurate disclosure.

2. Potential Risks and Side Effects

I acknowledge that each service carries inherent risks and side effects, including but not limited to:

• Aesthetic Treatments: Swelling, bruising, infection, allergic reaction, asymmetry, or rare nerve damage.

• IV Hydration Therapy: Vein irritation, fluid overload, phlebitis, or metabolic disturbances.

• Longevity Medications: Skin irritation, headaches, nausea, or rare cardiovascular events.

• Weight Loss Medications: Nausea, diarrhea, gallbladder disease, kidney injury, or risk of thyroid C-cell tumors.

• Peptide and Regenerative Therapies: * Common: Injection site reactions, water retention, increased hunger, or tiredness.

  • Serious/Rare: Infection, severe allergic reaction, hormonal fluctuations, or unknown long-term effects.

I understand that individual results vary and that no guarantees are made regarding the outcome of any treatment. I am responsible for seeking and paying for any follow-up medical care due to adverse reactions.

3. Release of Liability and Assumption of Risk

I voluntarily assume all risks associated with my treatment, including the use of peptides and regenerative therapies. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Axiom IV Hydration Therapy, Inc. DBA Axiom Healthspan, its distributors, vendors, manufacturers, or affiliates (“RELEASEES”) from any liability, claims, or demands arising from the use of these products, whether caused by negligence or otherwise.

Indemnification: I agree to indemnify, defend, and hold harmless Axiom Healthspan and all RELEASEES against any claims, liabilities, damages, or costs arising from my provider’s use of these products on my behalf.

4. Payment and Refund Policy

I acknowledge and agree to the following:

• No Refund Policy: All sales are final. No refunds will be issued for treatments, procedures, or shipped medications (including peptides).

• Prepayment Requirement: Full payment is required before the service or product is provided.

• Telehealth Program Refunds: If I do not qualify for a medication program after a telehealth consultation, I will be refunded the product cost minus credit card processing fees. No refunds are issued once medications have been shipped.

5. No-Show and Cancellation Policy

Appointments cancelled less than 24 hours prior to appointment start time could be subject to a $50 charge.

6. Telehealth Services

I acknowledge that telehealth consultations are not a substitute for emergency care and may be recorded for quality assurance in compliance with HIPAA. Full details: https://axiomhealthspan.com/telehealth-consent.

7. Consumer Privacy and Data Security

Axiom Healthspan complies with HIPAA. My health data will be handled as per the privacy policy found at https://axiomhealthspan.com/privacy and https://axiomhealthspan.com/consumer-privacy.

8. Arbitration Agreement

I agree that any disputes, including but not limited to medical malpractice claims or disputes arising from peptide/regenerative therapies, shall be resolved through binding arbitration, and I waive my right to a trial by jury.

• Governing Law: This Agreement shall be governed by the laws of the State of Pennsylvania.

• Procedures: Disputes must be submitted in writing. Both parties will select a mutually agreeable arbitrator and split costs equally.

• Full terms: https://axiomhealthspan.com/terms.

9. Acknowledgment and Consent

By signing below, I confirm that:

1. I have read and understand the risks, policies, and procedures outlined above.

2. I am at least 18 years of age and of sound mind to consent to these services.

3. I understand and agree to the No-Refund and Arbitration policies.

4. I consent to receive SMS notifications and marketing communications, with the ability to opt out at any time.

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