Consent IV Cinderella – velvet-and-pearls.com

Step 1 of 5 - Personal Information

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Name(Required)

Surname(Required)

Date of birth(Required)

DD dot MM dot YYYY

Address(Required)

Street Address City ZIP / Postal Code Country

Phone(Required)

Do you have any chronic diseases?(Required)

Yes

If yes, please specify:

Are you allergic to any of the components of this IV drip (NaCl, alpha-lipoic acid, vitamin C, glutathione)?(Required)

Yes

If yes, please specify:

Do you have kidney disease (e.g., chronic kidney failure, kidney stones)?(Required)

Yes

Do you have liver disease (e.g., cirrhosis, fatty liver, hepatitis)?(Required)

Yes

Do you have diabetes?(Required)

Yes

If yes, what medications are you taking?

Do you have hyperthyroidism or other hormonal disorders?(Required)

Yes

Do you have excess iron in your blood (e.g., hemochromatosis)?(Required)

Yes

Do you have asthma or other respiratory conditions?(Required)

Yes

Do you have any heart conditions (e.g., hypertension, heart failure)?(Required)

Yes

Do you have a history of blood clotting disorders or thrombosis?(Required)

Yes

Are you pregnant or breastfeeding?(Required)

Yes

Are you currently taking any medications or dietary supplements?(Required)

Yes

If yes, please list them:

Do you have a tendency to faint or experience sudden drops in blood pressure?(Required)

Yes

Have you ever had an allergic reaction to intravenous medications?(Required)

Yes

Do you currently have an active infection or fever?(Required)

Yes

Have you undergone chemotherapy or radiation therapy in the past three months?(Required)

Yes

When was your last blood test (CBC - Complete Blood Count)?(Required)

Have you ever had IV vitamin infusions before?(Required)

Yes

If yes, which ones and when?(Required)

Do you experience any of the following conditions that you hope this treatment will improve?(Required)

Chronic fatigue

Weakened immune system

Dull, tired-looking skin

Excessive stress

Other

Please specify

Do you have a tendency to retain fluids or experience swelling?(Required)

Yes

Do you have any other medical conditions that may affect your response to this IV drip?(Required)

Yes

If yes, please specify:(Required)

Consent(Required)

I confirm that all the above information is true and accurate to the best of my knowledge.

Consent(Required)

I have been informed about the possible side effects and the procedure of the treatment.

Consent(Required)

I give my consent to receive the "Cinderella" IV drip treatment.

Consent(Required)

By providing your information, you agree that Velvet & Pearls may securely store and process your data in accordance with applicable privacy regulations. Your information will be used solely for appointment management, service customization, and communication regarding our offerings. We value your privacy and will never share your data with third parties without your consent. For more details, please refer to our Privacy Policy.

Signature(Required)

Patient Questionnaire Before the "Cinderella" IV Drip Treatment