Personal information

Your full name*

Name Last name

Birth date*

Your address*

Address City ZIP code Country

Your phone*

Your e-mail*

Why do you plan to have an IV vitamin infusion?*

I feel tired

I want to boost my immune system

I've been to party and I'm in hangover

I want to increase my physical performance

I have skin problem and/or hair loss

Other

Have you ever received an IV Vitamin infusion in the past*

Yes

Do you have any health problems or health history ?*

Yes

Are you known to have allergies*

Yes

Are you taking any medications ?*

Yes

Have you drunk alcohol in the last 24 hours ?*

Yes

Do you smoke ?*

Yes

Have you taken any drugs in the last 24 hours ?*

Yes

Are you pregnant or breastfeeding ?

Yes

(women only)

Patients with Chronic KidneyDisease (CKD) and/or with heart problems (CHF, Atrial Fibrillation, CAD etc.) Patients that have a history of seizures.
Cancer patients – must have records and order from treating Oncologist/PCP prior to administering IV infusion.
Patients under 18 and over 75 years.
Pregnant Woman (except the "Basic Hydratation" perfusion).
Patients who require an in-person exam due to severe symptoms(feverish state, decline of general condition).
Patients who already had a side effect like allergic reaction to Vitamin IV perfusion or any other kind of vitamin injection.
Patients that take benzodiazepine and anti- seizure medication.

If at any point your nurse has a reason to believe that you are not suitable for IV infusion, the nurse will postpone the treatment or will propose you to do the first injection in the Lausanne's clinic under close medical monitoring.

I hereby certify that the information provided is complete and I undertake to notify him of any subsequent changes in my health status.

I confirm that the medical informations are accurate*

Yes, I confirm

Consent to medical care

a. I hereby authorize the health care providers of Yuboost, and their staff, to perform any medical procedures and medical care which in their professional judgment is deemed necessary to diagnose and/or treat the conditions that have brought about my seeking medical care services. I acknowledge that no guarantees are made to me concerning the outcomes of the treatment performed.

b. I agree that the staff of Yuboost has communicated to me the risks and benefits associated with each treatment I am agreeing to undertake and I have had an opportunity to ask the practitioner any questions I have regarding the risk associated with the treatment I am undertaking. Knowing each of those risks, I am agreeing to proceed with these services.

c. I accept that in the event of an accident involving a sting, a blood splash or any other injury involving blood contact, Yuboost's medical staff may carry out serological tests (blood screening) for hepatitis B, hepatitis C and HIV. This will be paid for by Yuboost.

Do you confirm that you validate the consent to medical care?*

Yes, I confirm

Date

Signature

Pre-injection medical survey

Personal information

Consent to medical care