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DRIP Health Questionnaire

Enjoy soothing IV infusions under professional medical supervision – for targeted recovery and renewed vitality.

personal dates

*

infusion

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infusion

Energy Push & Detox

Mayers Cocktail

High Dose Vitamin C Drip

Do you have any pre-existing medical conditions?

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Do you have any pre-existing medical conditions?

yes

no

If yes, which ones?

Do you take any long-term medication?

*

Do you take any long-term medication?

yes

no

If yes, which ones?

Do you have any allergies?

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Do you have any allergies?

yes

no

If yes, which ones?

date

*

signature

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Each guest assumes personal responsibility. By booking an appointment and submitting this form, you automatically agree to the liability waiver. The patient has been fully informed and consents to the discussed treatment.

signature