Personal Details

Name and Surname *

Age *

Occupation Industry

Employer

Mobile Number

Email Address

Physical Address

Emergency Contact Name *

Emergency Contact Phone Number *

Medical Aid Issuer

Medical Aid Number

Are you a Professional Athlete or licensed rider?(P.S. Professional Athletes are not allowed more than 100ml of saline according to World Anti-Doping Agency)

List Any Known Allergies (either to medication or food)

Are you taking any medication or Vitamins on a regular? (i.e. supplements)

Have you consulted with any specialist in the past 12 Months?

Where did you hear about us?

Any recent operations?

Any chronic conditions not listed above?

Legal disclaimer

I the undersigned hereby give consent to the health professional/nurse at Vitamin Drip House to administer the specific treatment of request, intravenously. I am aware that intrevenous treatment may have or cause undesired reactions. I'm aware of the possible risks (advantages and disadvantages) that may arise during or after the IV therapy and do so at my own risk. I am aware the Vitamin Drip House is a Nurse facilitated practice, and that the assigned qualified Registered Nurse has pleged their availability to assist.

I declare the I have been truthful with the information provided above about my health and well-being. I do not hold Vitamin Drip House liabe for any complications that may arise from the chosen treatment of IV infusion.

Disclaimer of liability in respect of harm or injury

The Client agree that Vitamin Drip House will not be liable for any and all claims as a result of any injuries or harm of whatsoever nature suffered by the client however costs proved, against Vitamin Drip House personnel for loss or damage (i.e. consequential damage or expense) incurred by the client.

I confirm that by signing the document, I agree to the above terms and conditions of the Vitamin Drip House, without being under any form of duress of any nature and that no personnel of Vitamin Drip House has passed any form of misinterpretation of the above or might have tried to influence my consent of the above in whatever way.

Enter your full name as acceptance of the above *

Date *