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 receiving the above-mentioned therapy.

The risks 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 I have the right to change my mind at any time before the procedure is undertaken, including after I have signed this form. I understand that I must inform my doctor if this occurs.

I consent to undergo the procedure/s or treatment/s as documented on this form.

I confirm that the request and consent for the procedure/treatment above remains current.

Indemnity:

Except where provided or required by law and such cannot be excluded, I agree that the VitaFuzion and its respective directors, officers, 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 Health Professions Council 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 application. I warrant that all information provided is true and correct.