Pre-injection medical survey

• 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.