Personal History

Del Mar Wellness Therapy Participation Waiver and Release of Liability

First Name *

Last Name *

Email *

Phone *

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Date of birth *

Sex Assigned at Birth *

Address

Address *

City *

State *

Country

Postal code *

Emergency Contact Information

Emergency Contact Name *

Relationship *

EC Phone Number *

Health History

Reason for visit *

Medications and Conditions

Please list current medications (including prescriptions, over-the-counter medications, vitamins, herbs and homeopathic remedies)

Current Medications *

Please list any allergies you have (including to medication) *

Have you ever had a vitamin or wellness IV? *

Yes

Any Complications *

Yes

Please explain complications *

Additional Health Questions

Please Check All That Apply

Are you pregnant? Currently attempting to be pregnant?

Are you a smoker or have a history of smoking?

Are you currently receiving or have recently undergone chemotherapy treatments?

Have you had a recent eye surgery related to vision impairment (e.g., Lasik)?

Have you had dental work in the last 24 to 48 hours?

None of the Above

Are you currently taking blood thinner medications? (ex. baby asprin, warfarin, plavix, etc.) *

Yes

Please list blood thinner medications below (dose and frequency)

Consent and Release of Liability

In consideration of the risk of injury while participating in therapies such as Hyperbaric Oxygen Therapy, CVAC, Red Light Therapy, Theta Bed, Pulsed Electromagnetic Field Therapy, IV and Injection Therapy, Hemealumen IV Therapy, NAD+ IV and Injection Therapy, and other treatments provided, I hereby agree, for myself, my heirs, executors, administrators, assigns, or personal representatives, to knowingly and voluntarily enter into this release of liability. I hereby waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in any therapy. I release and forever discharge Del Mar Wellness, located at 2675 Irvine Ave. Ste. C, Costa Mesa, CA 92627, from any physical or psychological injury that I may suffer as a direct or indirect result of my participation.

Acknowledgment of Risk

I am voluntarily participating in the aforementioned activities entirely at my own risk. I am aware of the risks, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, economic or emotional loss, and death. I assume all related risks, both known and unknown to me, of my participation.

Medical Treatment

In the event that I should require medical care or treatment, I authorize Del Mar Wellness to provide all emergency medical care deemed necessary. I agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment.

Medical Disclaimer

Del Mar Wellness does not diagnose, treat, or cure any medical conditions, including but not limited to cancer, autoimmune disorders, neurological conditions, or any other chronic or acute illnesses. The services provided—including but not limited to IV Therapy, Injections, Aesthetic services, Hyperbaric Oxygen Therapy, CVAC, Red Light Therapy, Theta Bed, Pulsed Electromagnetic Field Therapy, and other treatments—are elective, alternative therapies intended to support general wellness. These services are not designed to diagnose, treat, or cure illness and should not replace medical care from a licensed healthcare provider. Please consult your physician regarding any medical concerns prior to beginning any service.

Indemnity

I agree to indemnify, defend, and hold harmless Del Mar Wellness and its staff against any claims, suits, or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf.

Signature of Patient *

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