New Clients - Booking Request (Liebe Wellness)

NEW Client Form - Interested in having an IV Infusion?

We need some details about you so we know how best to support your wellness journey.
Full Name (of person requesting the IV infusion)*

First NameLast Name
Mobile Number*
Your home address (required for scripting)*

Unit Number or Building Name (Type NA if not applicable)

Street Address

SuburbState

Post Code
Client's Current Age:
Are you requesting -

Vitamin TherapyIron InfusionBoth
Tell us briefly what your wellness goal is. Why are you seeking IV or IM services? Do you already know what nutrients you are wanting?*
Do you have any questions that need to be answered prior to requesting a booking? (please note that the most appropriate script/protocol will be determined after your full medical history as been received).
Please provide us with two potential dates and times for your Infusion.

Your preferences are subject to availability and scheduling. Please note that same day service may not be available. Surcharges may apply for appointments at or after 7pm and on weekends and public holidays.
1st Preference - select a date*

DayMonthYear
First Preference Date
Select a time slot*
2nd Preference*

DayMonthYear
Second Preference Date
Select a time slot*
What happens now?

After you click Submit.
1. We will call/SMS you with our availability within 24 hours of receiving your form.
2. If you go ahead with a booking we will send you a Medical History Form that must be completed prior to us confirming your booking.
3. If our medical team deems an IV infusion or IM injection an appropriate treatment for your wellness goals and medical history, we will send you a deposit payment link to secure your appointment.
PLEASE NOTE:

The following policies apply:
- A booking fee is required to be paid to confirm your appointment. Your appointment time will be held for 24 hours only. Your booking fee for your first service includes a scripting fee.
- A cancellation fee equal to the booking fee will be charged if you cancel your appointment within 72 hours of your appointment time.
- If you need to re-schedule, please do so as soon as you can. Call or SMS us on 0421 250 140. Your booking fee is valid for one re-schedule only.
- If you don't arrive for your appointment, or our nurse arrives and you are not home, your card will be charged the full amount of your treatment.
- An after hours, weekend and public holiday surcharge of $50 may apply.
- A travel fee may be charged if you live more than 15kms from Melbourne CBD. This will be charged at 0.85cents p/km.
You will be informed of extra charges at the time of booking.

We look forward to treating you and working towards your health and wellness goals.

Robyn & the Euphoria team.
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NEW Client Form - Interested in having an IV Infusion?

Please provide us with two potential dates and times for your Infusion.

What happens now?