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Consent Form

Please complete this consent form before your IV Vitamin Infusion Therapy appointment. Once you sign, a copy is emailed to you and to Gemma automatically.

Your details

IV Vitamin Infusion Therapy — treatment information & disclaimer

IV infusion therapy delivers fluids, vitamins and nutrients directly into a vein through a cannula. It is a wellness treatment and is not intended to diagnose, treat, cure or prevent any medical condition, nor is it a substitute for medical care. Please inform your practitioner of all allergies, medications, supplements and your full medical history before treatment.

Occasional risks include discomfort, bruising and pain at the injection site. Rarely, inflammation of the vein (phlebitis), metabolic disturbance or injury may occur. Extremely rarely, severe allergic reaction/anaphylaxis, infection, cardiac events or other serious complications can occur, which would require emergency medical attention.

I confirm I have informed the practitioner of any known allergies and my medical history, and I understand the benefits and risks of intravenous therapy.

A non-refundable deposit is required to secure your appointment. The balance is payable at your appointment. Deposits and booking fees are non-refundable unless agreed with the practitioner.

Medical screening

Please answer honestly — this keeps your treatment safe. Add detail in the notes where relevant.

1. Are you pregnant, breastfeeding, or trying to get pregnant?
2. Do you have any medical conditions? If yes, please give details.
3. Are you taking any medication (including blood thinners such as Warfarin/Aspirin)? If yes, please list.
4. Do you have any allergies, or have you ever had anaphylaxis? If yes, please give details.
5. Do you have any skin or neuromuscular disorders?
6. Do you have diabetes, an autoimmune disease, or a bleeding/clotting disorder?
7. Do you have a history of keloid or hypertrophic (raised) scarring?
8. Do you have any active infection, cold sores, or inflammation at the treatment area?
9. Have you had this or a similar treatment before? If so, did you have any problems?
10. What are your aims and motivations for the treatment / desired outcome? Please give details.
11. Is there any other medical or social history we should know? Please give full details.
12. Do you understand the information provided and feel it is sufficient for you to consent?
13. Has your consent been given freely?

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