Please take a moment to read our Policies, Terms and Conditions.
If you have any questions regarding our services, therapies, policies or terms, please contact us and we will be happy to assist you.
NO REFUND POLICY
HydraFuse has a NO REFUND policy for completed infusions. Results vary and cannot be guaranteed. Refunds will not be issued even in the event you do not see improvement in your symptoms or if your symptoms worsen.
I acknowledge that I have read and understand the information stated above.
24 HOUR CANCELLATION and “NO SHOW” FEE POLICY
Please provide our office with 24-hour notice to change or cancel an appointment. Clients who do not attend a scheduled appointment or do not provide 24-hour notice to change a scheduled appointment may be responsible for a $50.00 service fee. This fee must be paid on or before the next scheduled appointment.
After two missed or cancelled appointments without the appropriate 24-hour notice, you may be placed on a same day scheduling policy for your treatments, which would not allow you to schedule any appointments in advance.
Thank you for your understanding.
CONSENT and AUTHORIZATION INTRAVENOUS THERAPY and INTRAMUSCULAR BOOSTER PROCEDURES
HydraFuse Health and Wellness (HydrxaFuse, LLC) provides facilities and personnel to assist in the performance of intravenous therapy(IV) and/or intramuscular injections. You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. This document is intended to serve as confirmation of informed consent for IV therapy and/or booster/vitamin shots as ordered by a physician at HydraFuse Health and Wellness (HydrxaFuse, LLC) which from this moment forward will be referred to as HydraFuse. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent.
The procedure involves inserting a needle into your vein or muscle and injecting the fluid and/or micronutrients (vitamins, minerals, amino acids, medications) discussed and selected for your wellness intravenous therapy. Alternatives to intravenous therapy are oral supplementation, oral agents, expectant management and/or dietary and lifestyle changes.
Risks and Benefits
Risks of intravenous and intramuscular therapy include, but are not limited to:
• Discomfort, bruising and pain at the site of injection
• Inflammation of the vein used for injection, phlebitis
• Injury to nerve, vascular, bone or other tissues
• Transient metabolic disturbances
• Severe allergic reaction, anaphylaxis, cardiac arrest and death
Benefits of intravenous therapy include, but are not limited to:
• Injectables are not affected by stomach or intestinal disease
• Total amount of infusion is available to the tissues
• More nutrients are available to cells by means of a high concentration gradient
• Higher doses of nutrients can be given than possible by mouth, without intestinal irritation.
You have the right to consent to or refuse any proposed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent of the procedure(s) ordered with any different or further procedures which, in the opinion of your physician, may be indicated. The procedure will be performed by or under the direction of the physician with or without qualified medical assistants. You agree to immediately report side effects, adverse effects or medical problems you experience during your treatments, including any unusual symptoms (whether or not those symptoms are described in this consent), to your HydraFuse medical personnel.
You hereby release HydraFuse, its medical personnel, its staff and your HydraFuse provider from any liability from any injury or damages you may suffer as a result of your failure to follow the HydraFuse medical personnel, HydraFuse staff and/or HydraFuse provider instructions and failure to follow the terms and conditions of this consent. In the event of a medical emergency, including but not limited to an allergic reaction, you agree to seek medical attention at an emergency room. You understand that HydraFuse, its staff, nor your HydraFuse medical personnel guarantees that you will experience definite or particular results from any treatments. You understand there is no implied or stated guarantee of success or effectiveness of any treatment.
INFORMED CONSENT FOR KETAMINE INFUSION DISCLOSURE OF OFF-LABEL USE
The Food and Drug Administration (FDA) approves drugs used in the United States for specific indications, routes of administration and dosages. A drug approved by the FDA undergoes a series of extensive drug trials to determine a drug both safe and effective for its indicated use. Postmarketing surveillance data is used to determine if an approved drug continues to be safe after approval--if not, the medication is taken off the market.
Since 1970, ketamine has maintained its FDA-approval as an anesthetic. When a drug is used "off-label",also known as experimental, it means the FDA- approved drug is being used for a disease not listed on the label, and/or in a dose or by a route not listed on the label. Physicians, based on their knowledge and on available current information, may use a drug for a use not indicated in the "approved" labeling if it seems reasonable or appropriate. This applies to the off-label use of ketamine for psychiatric and pain conditions.
1. PROCEDURE - KETAMINE INFUSION THERAPY
An intravenous line (IV) will be started in an extremity so you can receive ketamine. Your blood pressure, heart rate, heart rhythm and oxygen saturation will all be monitored throughout the infusion under the supervision of a physician.
2. RISKS/SIDE EFFECTS
Common risks include, but are not limited to, blood pressure changes needing treatment, changes or difficulty in breathing needing treatment or reactions to the medications used. Uncommon risks include, but are not limited to, unexpected or sometimes severe complications, injury to blood vessels, airway, dentition, convulsions, stroke or other brain damage, heart attack or other organ damage, aspiration, infection or death. Problems or complications may require admission to a hospital. Rarely do these complications occur.
We further reduce risk by ensuring you receive sub-anesthetic doses (low dose) of agent(s) and directly monitor and observe your status while employing any interventions necessary making complications unlikely to occur.
Risk of ketamine: Side effects normally depend on the dose and how quickly the injection is given. The dose being used is lower than anesthetic doses and will be given slowly over at least 40 minutes, longer for pain conditions. These side effects often go away on their own. Common side effects, greater than 1% and less than 10%:
• nausea and vomiting
• increased saliva production
• blurred vision
• increased heart rate and blood pressure during the infusion
• "dissociation" out of body experience during the infusion
• change in motor skills
These symptoms dissipate when the infusion is stopped. If they are severe, another ultra-rapid acting medication such as a sedative can be used to treat the symptoms. You should not drive the day of an infusion.
Uncommon side effects, greater than 0.1% and less than 1%:
• double vision
• pain and redness in the injection site -Increased pressure in the eye
• jerky arm movements resembling a seizure
Rare side effects, greater than 0.01% and less than 0.1%:
• allergic reaction
• irregular or slow heart rate
• low blood pressure
• cystitis of the bladder: inflammation, ulcers, and fibrosis
• Ketamine can cause various symptoms including but not limited to flashbacks, hallucinations, feelings of unhappiness, restlessness, anxiety, insomnia and disorientation.
• There is a potential risk of dosing error or unknown drug interaction that may require medical intervention including intubation (putting in a breathing tube), or hospitalization.
• The risk of venipuncture may include temporary discomfort from the needle stick, bruising, or infection.
• Fainting may also occur.
• Risk of discomfort in answering questionnaires about your mental health and drug and alcohol use.
• Risk of other medications interacting with ketamine. It is very important that you disclose all medications, both prescription and over the counter, that you are taking.
• Ketamine may not help your depression, bipolar disorder, PTSD or pain
Ketamine has been associated with a decrease in depression, bipolar, and PTSD symptoms with results lasting for days to weeks to months. There is no way to predict how any single person will respond to ketamine infusion therapy. These effects may not be long lasting and will most likely require further infusions.
4. Risk Management
You must report any unusual symptoms or side effects at once to the medical staff. On the day of the infusion, you should NOT engage in any of the following after the infusion:
• drinking alcohol or using drugs
• conducting business
• participating in activities which require you to rely on motor skills or memory
5. VOLUNTARY NATURE OF THE TREATMENT
You are free to choose to receive or not receive the ketamine infusion. Please tell the doctor if you do not wish to receive the infusion.
6. WITHDRAWAL OF TREATMENT
Your doctor has the right to stop the infusion at any time. They can stop the infusion with or without your consent for any reason.
7. PATIENT CONSENT
• I know that ketamine is not approved in the treatment of depression, bipolar disorder, PTSD or pain conditions.
• I know that other off-label agents may be used to manage or improve my response to ketamine and have been fully discussed.
• I know that my taking part in this procedure is my choice.
• I will undergo a physical examination by HydraFuse physician prior to the beginning of any treatments that require a physical examination
• I know that I may decide not to take part or to withdraw from the procedure at any time.
• I know that I can do this without penalty or loss of treatment to which I am entitled.
• I also know that the doctor may stop the infusion without my consent.
• I also know that ketamine infusion therapy may not help my pain, depression, bipolar, or PTSD and in very rare cases there is a risk of worsening symptoms.
• I have had a chance to ask the doctor questions about this treatment.
• They have answered those questions to my satisfaction.
• The nature and possible risks of a ketamine infusion have been fully explained to me.
• The possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me.
• No guarantees or assurances have been made or given to me about the results of treatment.
• I hereby release HydraFuse, its medical personnel, its staff and my HydraFuse provider from any liability from any injury or damages I may suffer as a result of my failure to follow the HydraFuse medical personnel, HydraFuse staff and/or HydraFuse provider instructions and failure to follow the terms and conditions of this consent.
CONSENT TO INFUSION(S) AND TREATMENT:
I acknowledge that the proposed infusion(s), the potential risks and benefits, and the possible complications of such treatments have been explained to me as well as the possible risks and benefits of not undergoing the infusion. I am aware that the infusion(s) is (are) an off-label use of an FDA approved medication and have discussed this with the physician. I was given adequate opportunity to ask questions pertaining to this treatment including patient education and post-treatment instructions. I further acknowledge that no guarantees or promises have been made to me concerning the results of any treatment. I acknowledge that the physicians at HydraFuse Health and Wellness are not my primary providers and I will need to continue medical care with my providers.
Having read this form and talked with the physician, I voluntarily give my authorization and consent for the infusion(s).
POLICY ON ADVANCE DIRECTIVES
It is the policy of HydraFuse Health and Wellness (Hydrxafuse, LLC) physicians and staff to “acknowledge” a patient’s right to have an Advance Directive and will file any advance directive that has been submitted or brought to our attention in the patient’s medical record. The patient’s medical record will be flagged as such.
In the unlikely event of deterioration of a patient while he or she is in our Center, it is our policy to stabilize that patient and transport them to the closest JCAHO accredited hospital with a copy of the advance directive if made available to us.
Your choice of infusions depends on the tier purchased. (All tiers exclude Hydra-Beauty and Hydra-Mega Immunity).
Sign up by calling (443)699-3265. A staff member will call you to set up a membership account.
There is no initiation fee.
As long as you meet the 5-month minimum requirement, you can cancel your membership thereafter. To cancel please email us at with your name, membership plan and reason for cancellation. We will remove you from the membership auto renew and your plan will deactivate the following month. You can use your remaining treatments per that month until your account automatically closes at the end of your billing cycle.
Treatments do NOT roll over from month to month.
You can share your infusions with family members with Tier 3 and 4 only. Family must be registered as such in our system.
Your account is charged once per month via auto pay. Memberships are automatically renewed after 12 payments (one year).