Treatment Form - I.V. Therapy

First Name *

Last Name *

Phone *

Email *

Street Address

City

Post Code

Date of birth

Consent to Treatment

I am voluntarily consenting to receive I.V. (intravenous) and/or I.M. (intramuscular) therapy administered by a qualified healthcare professional.

Yes

I understand that participating in intravenous hydration and vitamin administration carries potential risks and side effects, including but not limited to infection, allergic reactions, vein irritation, bruising, and electrolyte imbalances. *

Yes

I acknowledge that failure to disclose accurate and complete medical information—including current and past medical conditions, allergies, and medications—can increase the risk of complications. *

Yes

I am undertaking this treatment with full knowledge of potential outcomes, side effects, and risks. I will not hold the clinic, its staff, or practitioners responsible for any adverse effects that may result from the procedure. *

Yes

I understand that any medical care required as a result of the treatment—whether directly or indirectly related—will be my financial responsibility. *

Yes

I understand that the clinic and its practitioners are not responsible for screening for, diagnosing, monitoring, or treating any pre-existing conditions and that they rely solely on the information I provide. *

Yes

I acknowledge that I have been given the opportunity to ask questions about the treatment, including its nature, purpose, risks, and potential complications. My questions have been answered to my satisfaction. *

Yes

I understand that it is not possible to anticipate or explain every potential risk or outcome. I waive any and all claims related to the services provided and agree to hold the clinic and practitioner harmless regarding any complications experienced during or after the service. *

Yes

Medical Screening Questions

Please answer the following truthfully. If any answer is “Yes,” please provide details.

Do you have a history of anaphylactic shock or severe allergic reactions? *

Yes

Do you have any known allergies? *

Yes

If yes specify:

Do you have liver or kidney disease? *

Yes

Are you currently undergoing treatment for cancer or had cancer in the last 5 years? *

Yes

Do you suffer from or have a history of Deep Vein Thrombosis (DVT)? *

Yes

Are you taking aspirin, warfarin, anti-coagulants, or supplements (e.g., Omega-3) that affect bleeding time? *

Yes

Are you taking/receiving steroids, chemotherapy, or radiotherapy? *

Yes

Are you currently taking any medications? *

Yes

If YES, Please specify;

Do you have any of the following illnesses: diabetes, angina, epilepsy, hepatitis, autoimmune disease? *

Yes

Do you suffer from keloid or hypertrophic scarring? *

Yes

Do you have a history of cold sores (herpes simplex) or other skin infections? *

Yes

Have you had or do you have a cardiac condition? *

Yes

Are you currently pregnant or possibly pregnant? *

Yes

Are you breastfeeding? *

Yes

Have you experienced oedema (swelling/fluid retention)? *

Yes

Have you consumed alcohol or recreational drugs in the past 48 hours? *

Yes

Additional comments:

Data Protection (GDPR)

In accordance with GDPR, I understand:

I have the right to access, rectify, or request deletion of my personal data.
My data will be securely stored for no longer than 6 years for legal and insurance purposes.
After 6 years, digital data will be permanently deleted and paper records destroyed.
All personal data is stored on password-protected devices or in locked filing cabinets accessible only to authorized staff.

Acknowledgment & Signature

I confirm that:

I have read and fully understand the information provided above.
I have answered all health-related questions truthfully and to the best of my knowledge.
I consent voluntarily to receive I.V./I.M. therapy.
I understand that I may withdraw my consent at any time prior to treatment.

Person we can contact in case of emergency / next to kin *

Relationship *

Contact number *

Client Signature: *

Clear

Practitioner Signature: *

Clear

Date *

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