Terms of Service

Effective Date: 05/08/2025

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IV Infusion And Injection Therapy Consent Form

I, the individual patient whose name and signature appears below ("You" or "Your"), do hereby request and consent to an evaluation and treatment by Nikuwa LLC, doing business as Peach IV ("Peach IV"), its healthcare providers and staff (collectively, “Provider” or "We"). You wish to rely on Provider to exercise judgment for Your best interest, the below-named patient, during the course of treatment. You will inform Provider of any sensitive areas or adverse conditions that You may have had prior to, during or after treatment. You intend this consent to always cover the entire course of treatment and in the future.

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This form outlines that You understand that a peripheral intravenous catheter will be inserted into a vein in Your body, and You will have fluids, vitamins, minerals, nutrients, and/or medications infused directly into Your body. This is considered “IV Infusion Therapy.” If You are having injection therapy, then You understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of Your body. This is considered “Injection Therapy.”

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Consent For Treatment

You hereby authorize Provider to provide You with healthcare treatment, including without limitation medical, diagnostic, nutritional treatment, (collectively, the "Treatment") administered by Provider. You understand that the practice of health care/medicine is not an exact science and that diagnosis and treatment may involve risk of injury or death. You acknowledge that We have not made any guarantees or promises as to the outcome or the safety and efficacy of the treatment. You certify that You are of sound mind and body to make medical decisions and to consent for treatment.

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Voluntary Nature Of Treatment And Alternative Therapies

You affirm that You are voluntarily seeking IV Infusion Therapy and Injection Therapy at Peach IV and have not been coerced into doing so. You acknowledge that IV Infusion Therapy and Injection Therapy at Peach IV is voluntary in nature and You are seeking out this Therapy of Your own or from the recommendation of Your referred provider. Treatment with IV and injectable vitamins/hydration/nutritional/mineral and/or medications offered at Peach IV is completely voluntary in nature. Alternative therapy for the symptoms You are seeking IV Infusion Therapy and Injection Therapy for include, but are not limited to, ongoing treatment by Your primary care provider and/or specialty provider, oral supplementation, and dietary/lifestyle modifications. You have been informed that there are alternatives to the treatments, including surgery, other types of injections, prescription medication, and taking no action.

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Experimental Nature of Treatment

You acknowledge and agree that the evaluation, diagnosis and treatments may consist in whole or part of experimental procedures and methods, including without limitation intravenous micro-nutrient therapy, on which no governmental (including the U.S. Food and Drug Administration ("FDA")), scientific or medical authority has issued any guidelines or statements as to the safety or efficacy thereof. You acknowledge that the safety record of the treatments appear to be relatively safe. We have informed You that the treatments may alter, address, or decrease pain, symptoms or complaints, but may also have no effect.

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Risks, Side Effects, Complications

We, Provider, hereby inform You that there are certain unavoidable risks and potential side effects and complications to the treatments, including without limitation, infections; swelling; increased pain; bleeding; scarring; scar or wound enlargement; Keloid formation; asymmetry; temporary or permanent alterations in sensation; allergic reaction; discoloration; the need for additional surgery; soreness; itching; injury to nerves; excessive fluid retention; breathing difficulty; respiratory complications involving excessive fluid; internal or external leaking of fluid; feeling of "lumpiness" or permanent skin contour irregularities; pneumothorax; spinal cord injuries; tingling; paralysis; no benefit of treatment; dizziness; exacerbation of preexisting conditions; or other serious or debilitating injuries or death.

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Description Of Treatments

You acknowledge that the treatments may involve insertion of needles into Your skin, muscle and veins and injection of standardized formulas, which may or may not be compounded by licensed medical professionals employed by Provider. These may include various nutritional substances, homeopathic medicines, FDA-approved medications, local anesthetic, concentrated sugar/electrolytes, and, on occasion, local subcutaneous anesthetic infiltration. The exact solution and site of injection for Your treatment as well as recommended sequence of treatments, will be explained to You when We, Provider, administer the treatment.

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Health Care Staff

You are aware that among those who attend You on Your behalf are medical, nursing, and other health care personnel in training, who unless requested otherwise, may participate in patient care as part of their education. You further consent to the presence of service representatives and/or technicians from manufacturers of equipment and/or devices during procedures and treatments. These workforce members have signed confidentiality agreements with Us, Provider.

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Information You Provide Us

You have provided Us, Provider, with a complete list of all prescription and non-prescription medications and dietary supplements You are currently taking, and You agree to update Us periodically should this list change. You have provided Us, Provider, with a complete list of all known allergies You may have, and all allergic or adverse reactions You have had in the past to medicine, dietary supplements or medical treatments of any kind. You covenant that all the information You provide Us, Provider, during the course of treatment is true, accurate, complete, and up-to-date to the best of Your knowledge.

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Assumption Of Risk

Your hereby acknowledge that after having read carefully and understood fully the terms of this agreement, and after adequate time to ask any questions about this agreement or treatment, You are willing to assume any and all risks associated with the treatment, including without limitation those described in this agreement. You acknowledge that no explanation or description of the treatments can ever fully explain every possible risk, side effect, or complication that may or could arise from the treatments, but by signing this, You nevertheless acknowledge Your willingness to assume such risks and that Your consent to the treatment is willing, voluntary, and informed.

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Treatment And Transport In The Case Of Emergency

You give Your consent for the use of emergency intervention if required during treatment. You request and consent to be transported by Provider and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during the course of Your treatment by Provider.

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Miscellaneous

You agree that this agreement constitutes the entire agreement between You and Us, Provider, regarding the subject matter hereof. No promise, representation, guarantee, or warranty not included in this agreement has been or is being relied upon by You. This agreement is binding on You and Your successors, heirs, legal representative, first-of-kin, and any health care proxy. In case any one of the provisions in this agreement is held invalid or illegal, such provisions shall be curtailed, limited, or severed only to the extent necessary to remove such illegality and invalidity. This agreement shall be governed by the laws of the state of New York ("Governing Law") without regard to any choice of the law principal. Any dispute between You and Us, Provider, shall be adjudicated in state or federal court in New York and You submit to the jurisdiction of any such court.

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Final Statement

You release Provider at Peach IV and all medical staff from all liabilities for any complications or damages associated with IV Infusion Therapy and Injection Therapy.

You have read this consent and fully understand the information within it and You voluntarily authorize and consent to the treatment options, including but not limited to IV Infusion Therapy and Injection Therapy, provided by Peach IV.

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