NEW CLIENT INTAKE FORM - I.V.

Please fill and submit this form prior to your appointment. 
If you are unsure about any of the questions, please complete as best you can and consult your therapist. You cannot begin your treatment without completing.


Name *
Name
Sex *
Are you residing in Bali? *
How did you hear about Aqua Health Spa? *
Is this your first IV treatment? *
What is the main reason for your visit today? *
CANCELLATION POLICY / REFUND POLICY: *
Appointments must be cancelled or changed at least 24 hours in advance of your scheduled booking, otherwise you will be billed for the total cost of the services. There can be no refunds for treatments once payment has been made.
IV therapy is not intended to replace the relationship with your primary health care providers and your consultation with a nurse is not intended as medical advice. The therapist intends only to share their knowledge and information from their education, research, training, and experience. I agree to make my own health care decisions based upon my own research and in partnership with my primary health care provider, doctor or naturopath. The information and service provided is not used to prescribe, recommend, diagnose or treat a health problem or disease. It is not a substitute for medical care. I am aware that there are risks associated with IV therapy including, but not limited to itching, bruising, dizzyness, superficial phlebitis (tenderness of the vein), immune modulation (simulating a fever) allergic reactions and hypersensitivity such as anaphylactic shock. I am fully aware that Aqua Natural Health or its employees do not claim to cure or treat any condition or disease with IV therapy. Please schedule an appointment with our doctor for more comprehensive advice. I consent and authorize a staff member of Aqua Health Spa who has been trained in Vitamin IV to perform treatments on me. I certify that I have read this entire informed consent and that I understand and agree to the information provided in this form. I understand that this treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Possible Side effects Bruising (may last from 1 to several weeks) Itching (temporary along the vein) Allergic reaction Hypersensitivity (such as anaphylactic shock) Superficial Phlebitis (a benign condition with redness, tenderness and increased heat of the skin) Immune modulation (simulation of fever) Headaches and dizziness (usually due to lack of fluids)
CONTRAINDICATIONS:
A contraindication is a symptom or health history that makes it unsafe or inadvisable to have a particular therapy. Please check any box which may apply to you...(Written consent from your medical practitioner may deem you eligible for treatment).
By checking the box below, I confirm that I have read and understand the Aqua Natural Health contraindications policy and cancellation policy and am fully aware of all the disclaimer information and the possible side effects of IV therapy and have educated myself on the treatment for any side effects. *
Name (as electronically signed) *
Name (as electronically signed)