Client Information And Consent Form

Personal Information

First Name *

Last Name *

Date of Birth *

Email

Contact number *

Address *

Street address *

City *

State *

Postcode *

Are You An Existing HyDRalyfe or Drip Hydration Customer? *

YesNo

Are you of Aboriginal and/or Torres Strait Islander origin?

YesNoPrefer not to say.

Gender Identity

MaleFemaleNon-BinaryGender Diverse

Does your current gender identity differ from when you were born?

YesNo

Health and Service Information

Do you have any medical conditions or health problems we should be aware of? *

YesNo

Please specify *

Have you ever had IV Therapy before? *

YesNo

Please Specify?

Have you ever had issues having blood taken or IV being inserted? *

YesNo

Please Specify *

Main reason for seeking treatment? *Please provide some information on how we can help and what you're hoping to achieve.

Please provide detail on any past illnesses or circumstances that may be affecting your wellbeing

My height in centimeters is

My current weight in kilograms is *

Are you over 18? *

YesNo

Specify Other

Do you often eat fruits and vegetables?

EverydayNow and thenHardly everI don't like fruits and vegetables so never

Are there any foods you don't eat?

Please select any and all that apply to you.

I drink 3 standard drinks per day or more than 15 standard drinks per week.I smokeI have recently used recreational drugs. I'm frequently under stress. I sleep less than 6 hours a night. None of the above apply to me.

Specify Other

Do you have any known allergies or hypersensitivity? *

YesNo

Please provide details if yes selected *

Have you undergone surgery in the past 12 months? *

YesNo

Please Specify

Are you currently pregnant? Breastfeeding or planning to become pregnant? *

YesNo

Specify Other

Are you currently taking any medications or health supplements (prescribed or otherwise)? *

YesNo

If yes, please list all you are taking with a brief description *

Are you vegan or vegetarian?

YesNoPrefer not to say

We only ask this question to ensure all products used in your infusion are vegan safe. Some suppliers can use nutrients derived from animal product

Please provide your Emergency contact's name

Emergency contact phone number

Is There Anything Else You Think We Should Know About?I.e. difficulty finding veins? Any previous issues when cannulating or difficulty when having bloods taken from you?

If you have your last blood results please upload them so we can personalise your service

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Informed Consent And Authority Collection

Please ensure you read the informed consent and ask your nurse or practitioner any questions you're unsure of.

Date

Authorised Collection Consent Form *

Informed Consent *

Signature *

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