How to Book

MEDICAL QUESTIONNAIRE AND SCREENING FORM


General Information


Personal information



Full Name*:

Address*:

Date of Birth*:

Email*:

Contact Number:


Sex: MaleFemale


Present Medical History


Do you suffer from high blood pressure? If yes, please specify what medication you are taking in comments section:
YesNo


Have you had diarrhea or vomiting within the last 7 days?
YesNo


Are you pregnant or breastfeeding?
YesNo


Comments:


List any prescription medications you are now taking:


List any self-prescribed medications, dietary supplements, or vitamins you are now taking:

List any other medical or diagnostic test you have had in the past two years:

List hospitalizations, including dates of and reasons for hospitalization:

List any drug allergies:

Indemnity and Consent


Family information


Next Of Kin (1):

Mobile:

Daytime Phone Number:

After Hours Phone Number:


Consent

Permission for intravenous vitamin therapy:

I hereby consent to receive the above- mentioned therapy
The risks and side effect of the procedure have been explained to me, including the risks that are specific to me, and the likely outcomes.

I understand that the result/ outcome of the treatment/procedure cannot be guaranteed. I understand that if immediate life-threatening events happen during the procedure, I will be treated accordingly. I understand that this is a non-refundable procedure. I consent to undergo the procedure/s or treatment as documented on this form. I confirm that the request and consent for the procedure/treatment above remains current.


I agree to execute a medical release so that all previously identified medical records of mine may be obtained from previous physicians, and I have disclosed openly any known previous disorders.
I understand that this therapy should not be used if I am pregnant or breast feeding.


I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through my conversations with my treating medical professional.


I acknowledge that I have had the opportunity to ask any questions to the medical
professional with respect to the proposed therapy and the procedures to be utilized and all my questions have been answered to my full satisfaction. My Signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of the IV therapy.


Indemnity:

Except where provided or required by law and such cannot be excluded. I agree that
Vitafuzion, its subsidiaries, directors, staff, members, servants or agents are absolved from all liability however arising from injury or damage to me.


Note: Our products have not been approved by the medical control council of South Africa. I have read, understood and agree to the above terms. I warrant that all information provided is true and correct.


I have read, understood and agree to the above terms and I personally consent to the procedure.

Full Name*:

Date*: