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IV DRIP THERAPY – PATIENT INTAKE FORM
Basic Information
Gender*
Health History Do you currently have or have had any of the following? (Check all that apply):
Are you currently taking any medications or supplements?
Any known allergies? (including vitamins, medications, foods): *
Do you smoke or use tobacco?
Do you consume alcohol?
Do you use recreational drugs?
Please select any that apply to how you currently feel:
What are your main goals with IV Drip therapy? (check all that apply):
I accept the privacy policy and the data protection act*
Consent & Understanding

By signing below, I confirm that:

  • I have answered truthfully and to the best of my knowledge.
  • I understand the nature and purpose of IV drip therapy.
  • I am aware of possible side effects including minor bruising, irritation, or allergic reaction.
  • I understand this is not a substitute for medical treatment of chronic illness.
  • I consent to proceed with the IV therapy under the supervision of qualified  nursing professionals.
We are dedicated to protecting your privacy. This policy outlines how we collect, use, disclose, and safeguard your personal information. If you want to know more about how we handle your information

Visit our Privacy Policy for more information

 

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We are committed to delivering high-quality care with our body lift procedures. While individual results can vary, we strive to meet your expectations and encourage you to discuss your goals with our specialists. If you feel unsatisfied after three months, we offer a complimentary consultation to explore potential adjustments. Your satisfaction and safety are our top priorities.
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