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Start Your Appointment Request
Please complete this form so we can ensure you receive the best possible care on the day. Once your form has been reviewed, we will contact you with a date and time for your appointment.
First Name
*
Last Name
*
Phone
*
Email
*
Address
*
Select Gender
*
Birthday
*
Which drip(s) are you interested in having?
*
Which drip(s) are you interested in having?
Do you suffer from any known medical conditions?
*
Do you suffer from any known medical conditions?
A
Yes
B
No
If yes, please specify:
Are you a professional athlete subject to WADA testing?
*
Are you a professional athlete subject to WADA testing?
A
Yes
B
No
Do you suffer from any of the following:
*
Untitled checkboxes field
Diabetes
Glucose 6 Phosphate Deficiency
Deep Vein Thrombosis (DVT) or Blood Clotting Disorder
Anemia
Sickle Cell Disease, Spherocytosis, Thalassaemia
Epilepsy or Seizures
History of Stroke or Haemorrhagic Stroke
Thyroid Disorders
Parathyroid Disorders
Kidney Disease
Liver Disease
Cancer ( Current or Past)
Osteoporosis
Allergies including Shellfish, Medication or Food
None of the above
Do you have any allergies?
*
Do you have any allergies?
A
Yes
B
No
If yes, please list:
Have you had IV Therapy before?
*
Have you had IV Therapy before?
A
Yes
B
No
If yes, were there any adverse reactions?
Do you drink alcohol?
*
Do you drink alcohol?
A
Yes
B
No
Do you smoke or use tobacco/nicotine products?
*
Do you smoke or use tobacco/nicotine products?
A
Yes
B
No
Please list any supplements, medications or vitamins you are currently taking
On a scale from 1-5, how healthy do you consider yourself to be?
*
On a scale from 1-5, how healthy do you consider yourself to be?
1
2
3
4
5
Date
*
I agree to the use of electronic signatures
*
I agree to the use of electronic signatures
I agree to the use of electronic signatures
Please sign here
*
Signature
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