TERMS & CONDITIONS

Informed Consent:

I understand that as a patient I have a right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent as to whether or not to receive care having had the opportunity to discuss potential benefits, risks and hazards involved.

I hereby request and voluntarily consent to examination and initial and continuing treatment with IV therapies of vitamins, micronutrients, supplements, chelation, detoxification, injections, lab testing, nutrition, and placement of an IV catheter (“Treatment”) by Dr. Mohammad Mahdi Paryavi, a licensed physician, and/or any other licensed practitioner (nurse practitioner or registered nurse) acting under the supervision of Dr. Paryavi I understand that in supervising the other licensed practitioners, Dr. Paryavi may not be physically on the premises at the time I receive treatment.

I understand that I can request explanation of the procedure or methods of treatment, and information about the material risk of the Treatment. I also understand that providers cannot make guarantees of successful treatment, and I have not been guaranteed any specific benefit or results related to the Treatment.

I understand that there are advantages to intravenous nutritional therapy over oral supplementation or dietary changes: (i) not affected by stomach or intestinal disease, (ii) total amount given is available to tissue requiring the constituents, (iii) give doses of nutrients higher than those possible by mouth without intestinal irritation, and (iv) actively push nutrients into cells by means of a high concentration gradient despite low energy due to illness.

I understand as with drugs, nutritional supplements and IV therapy nutrients may exhibit some side effects in certain sensitive individuals, may interact with certain medications or lab tests, or show symptoms due to certain preexisting disease conditions. I also understand that the Treatment has risks and that the following possible complications could, although unlikely, occur during or following the Treatment: (i) irritation bruising at the site of the IV insertion or the vein itself (phlebitis), (ii) infection, (iii) bleeding, (iv) allergic reaction to the infused vitamins, minerals or compounds including anaphylaxis (which can be life threatening), (v) nausea or upset stomach, (vi) dizziness, feeling faint, or changes in blood pressure and blood sugar, and (vii) other rare, but possible side effects, such as fever, difficulty breathing, heart abnormalities (including arrhythmias), and stroke. I understand it is impossible to list every possible undesirable effect and that the condition for which this procedure or treatment is being done may not be cured or significantly improved, and in rare cases may become worse.

I agree to follow these guidelines prior to each Treatment: (i) stay well hydrated by drinking adequate water the day of your treatment, (ii) inform provider of any allergies to any nutrient, lidocaine, metal, or any other allergy I may have prior to treatment, (iii) inform provider if I am or become pregnant, have kidney failure or liver disease, and (iv) tell provider of any fears you may have about your treatment so they can be addressed prior to treatment. I also agree to notify provider immediately if I experience any adverse reaction related to the Treatment whether during or after the Treatment.

I agree that if I post a video, audio, image, text or other medium ("Content") regarding my Treatment from Dripology LLC on any social media accounts including but not limited to Instagram, Facebook and Youtube, I grant Dripology LLC permission to use the same Content on its social media accounts.

I agree that if I am receiving a promotional, collaborative or complimentary Treatment from Dripology LLC, I will promote Dripology LLC's brand, products and services on my social media accounts and permit Dripology LLC to use the same Content to on its social media accounts.

I certify this form has been fully explained to me, and that I have read and understand it. I have been educated on the benefits, risks, and possible adverse reactions associated with the Treatment. I have been given the opportunity to ask any questions about the Treatment and have had them answered to my satisfaction. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I fully understand what I am signing and hereby request and consent to the Treatment.

I understand that I am free to withdraw my consent and to discontinue participation in these treatments at any time.

PATIENT-PHYSICIAN ARBITRATION AGREEMENT

ARTICLE 1

Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

ARTICLE 2

All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates/ association, corporation, partnership, employees, agents and estate, must be arbitrated including without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.

ARTICLE 3

Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties’ consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this arbitration agreement, including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (Civil Code 3333.1), the limitation on recovery for non-economic losses (Civil Code 3333.2), and the right to have a judgment for future damages conformed to periodic payments (CCP 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

ARTICLE 4

General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

ARTICLE 5

Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties.

ARTICLE 6

Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. Effective as of the date of first professional services.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY CHECKING BELOW, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.