I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. The treatments I receive here are voluntary. I understand there is a risk, including but not limited to, allergic reaction, skin irritation, nausea, vomiting, gastrointestinal upset, and flushing. I release Recovery Hydration Therapy, INC and my provider from liability and assume full responsibility.