Full Name *

Date of Birth *

Email Address *

Your Phone # *

Group Code

Emergency Contact

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Emergency Phone #

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I understand and acknowledge that I am voluntarily consenting to receive intravenous (IV) therapy treatment. I understand that the treatment involves insertion of a small needle into a vein to administer fluids, medications, and vitamins.I acknowledge that, although IV therapy is generally safe, there are inherent risks and potential side effects associated with this procedure. These risks include, but are not limited to:

I understand that the risks and potential side effects listed above are not exhaustive, and other unforeseen risks may arise. I agree that if I experience any of these side effects, I will contact my therapist and, if necessary, seek medical attention at my own expense. I understand that it is my responsibility to disclose any health condition or medication that might affect the treatment.

You acknowledge risks and agree to treatment? *

I confirm that I have been fully informed on the potential risks, benefits, and complications and I voluntarily agree to undergo the treatment. I release Festie Bestie IV Hydration from any liability claims arising from the treatment.

Do you have a history of cardiac problems, kidney disease, or any other medical problems?

Do you have any allergies, especially to any vitamins or medicines?

Please list any medication you take, including supplements or aspirin:

Have you received IV therapy before?

Yes

Do you have phobia or needles?

Yes

What's your reason for seeking IV Therapy?

Please Confirm: *

I acknowledge that I have provided complete and accurate information and understand that it will be used to assess my suitability for any treatment.

I agree to waive all liabilities of Festie Bestie IV Hydration for any injury or damages incurred due to misrepresentation of my health history.

Client Signature

Clear

Signature Date