Medical Intake Form
Quick Health Check - Then I'll be in Touch
Full Name
*
First Name
Last Name
Home Address (required for prescription)
*
Unit Number or Building Name (TYPE N/A IF NOT APPLICABLE)
Street Address
Suburb
State
Post Code
Please provide the address where you will be having your IV services?
*
Home address as above
Different address
Address for treatment (if different to Home Address)
Unit Number or Building Name
Street Address Line 2
Suburb
State
Post Code
Mobile Number
*
Format: 0000 000 000.
Email
*
example@example.com
Date of Birth
*
/
Day
/
Month
Year
Example: 21/10/1973
Select the conditions that you currently suffer from or have suffered in the past:
*
Asthma
Fluid Restriction Regime (been advised to limit fluid intake)
Iron overload disorder
Herpes Virus
Autoimmune Disorder
Currently taking Anticoagulant Therapy
Seizure Disorders
History of Kidney Stones
Cobalt Allergy or Sensitivity
Polycythemia Vera
Graves Disease/Hashimotos Thyroiditis
Congestive heart failure
Heart disease or other heart condition
Diabetes
Metabolic alkalosis
Psychiatric disorder
Sickle-cell anemia
Glucose-6-phoshate dehydrogenase (G6PD) deficiency
Diminished renal function or any other kidney problem
Ischemic stroke
Liver disease as consequence of alcoholism or severe reduction in kidney function
Hypersensitivity to sodium lactate
Extracelluar hyper hydration or hypervolemia
Uncompensated cardiac failure
Hypercalcemia or Hyperkalemia
Ascetic cirrhosis or severe metabolic acidosis
Conditions associated with increased lactate levels (hyperlactatemia) including:
Concomitant digitals therapy
None of the above
Select any that apply: (this question will help us tailor your treatment needs)
I drink 3 or more standard drinks per day or more than 15 standard drinks per week
I smoke cigarettes
I am vegetarian/vegan
I have recently used recreational drugs (including marijuana)
Are you under the care of a specialist?
*
Yes
No
If yes, please provide name of specialist and specialisation (eg. oncologist, cardiologist). Type NA if the question is not applicable.
*
Have you been diagnosed with Cancer?
*
Yes
No
If yes to the above question, please provided details such as type of cancer, year diagnosed and whether you had or are having chemotherapy or radiation.
Are you suffering any major illnesses not listed above? If yes, please provide details.
*
Yes
No
List major illnesses here. Type NA if the question is not applicable.
*
Are you taking any medications and/or drugs (including over the counter medications and/or vitamins? If yes, please provide details.
*
Yes
No
List medications/drugs/vitamins here. Type NA is not applicable.
*
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you have any genetic conditions that you are aware of?
*
Yes
No
If yes, please provide details
Have you had surgery or a medical procedure in the last month OR are scheduled to have surgery or a medical procedure in the next 2 weeks?
*
Yes
No
Please provide details if the answer above is YES.
Have you ever had an issue with cannulation? Eg. difficulty with veins, fainting etc.
*
Yes
No
NA
Please provide details if the answer above is YES.
Have you ever had an allergic reaction to an intravenous vitamin therapy? If yes, please provide details.
*
Yes
No
NA
Details of allergic reaction.
Please list all other allergies or any other relevant information relevant to your treatment. Type NA if not applicable
*
Are there any other aspects of your health that you think we should know about?
*
Yes
No
List here.
*
Please detail the symptoms or concerns that you would like to address with IV Therapy (eg. stress, fatigue, immune system concerns, post viral illness)
*
Next of Kin
Please provide details of your next of kin
Next of Kin's name
*
First Name
Last Name
Mobile Phone Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Relationship to Next of Kin
*
Please Select
Spouse/Partner
Parent
Sibling
Child
Other relative
Friend
IV Vitamin Infusion and Emergency Care Acknowledgement
I understand that IV vitamin infusions are intended as supportive and complementary wellness care. They are not designed to diagnose, treat, cure, or prevent any medical condition or disease. These infusions are not a substitute for medical treatment or advice from a licensed healthcare provider. I acknowledge that it is my responsibility to consult with my physician regarding any medical concerns or conditions I may have. By proceeding with treatment, I confirm that I have read and understand this information.
*
Yes
No
In the event of a medical emergency, including but not limited to allergic reactions or other adverse events during or after treatment, emergency services (such as an ambulance) may be contacted to ensure your safety. You acknowledge and accept full financial responsibility for any costs associated with emergency medical care, including ambulance transport, hospital admission, and any further treatment required. By proceeding with treatment, you understand and agree to these terms.
*
Yes
No
You agree that ALL sections of this medical form are completed accurately and truthfully. Providing incomplete or incorrect information may impact the safety and effectiveness of the care you receive. It is your responsibility to disclose all relevant medical history, allergies, medications, and health conditions. Failure to do so could result in complications during or after treatment. We cannot be held liable for any adverse outcomes resulting from incomplete or inaccurate information provided.
Date
*
-
Day
-
Month
Year
Date
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