Thank you for your order!

You are consenting to receive text messages or phone calls regarding your appointment.

You consent and acknowledge that you may be contacted regarding your appointment and/or services related to your appointment.

This can be done either by phone, email, text (including Whatsapp)

Please only put your street address

Example:

1235 Anywhere Ln.

Houston, TX 77071

Please confirm your Zip Code

We can not always guarantee exact requested time slots but will do all we can to accommodate.

Examples:

• Gate codes for entry
• Pets
• Special care instructions

Select ALL that apply OR "None of the above and none mentioned"

Select ALL that apply OR "None of the above and none mentioned"

Please list all known allergies.

Acknowledgement and Liability Release :

By submitting this form and proceeding with your appointment you acknowledge and agree to the following:

In the event of a medical emergency, dial 911 immediately.

By proceeding with your appointment you acknowledge that this service is NOT a substitute for medical care, does not constitute a medical visit or evaluation and should not be used instead of calling your doctor or 911 in the event of a medical emergency.

The RN (nurse), Medic (paramedic), or other licensed individuals who will perform the service(s) are independently contracted and you will not hold them, Myhealthsight LLC, Gold Diagnostics Corp and its managers or affiliates, liable for any damages or loss(es) due to the services performed or not performed through our encounter.

By submitting and proceeding with your appointment you waive all rights for legal action or compensation from Myhealthsight LLC, Gold Diagnostics Corp and/or its affiliates.

We reserve the right to refuse service.

Some side effects from IV Therapy may include (not limited to)

Infection at the injection site or rashes, vein inflammation and bruising, swelling, muscle pain, blood clots or air embolism.