1.1 First Name: *

1.2 Last Name: *

1.3 Email Address: *

1.4 Phone: *

1.5 Home Address: *

1.6 City: *

1.7 Eircode:

1.9 Date of Birth: *

1.10 Age: *

2.18 Allergies (Please specify, or type NO): *

2.19 Allergic Reactions (Please specify, or type NO): *

2.20 Underlying Health Conditions (Please specify, or type NO): *

2.21 Any Medications by prescription or over-the-counter (Please specify, or type NO): *

Q17. Have You done IV infusions or vitamins therapies before?: * Q17. Have You done IV infusions or vitamins therapies before?: * Yes No

Q18. Do You have a fear of needles (needle phobia)?: * Q18. Do You have a fear of needles (needle phobia)?: * Yes No

Q19. Have You ever experienced difficulty with the insertion of a needle (i.e. fainting, bruising, difficult veins)?: * Q19. Have You ever experienced difficulty with the insertion of a needle (i.e. fainting, bruising, difficult veins)?: * Yes No

v v All above information is true to the best of my knowledge. I understand that IV therapy involves the insertion of a needle and the infusion of vitamins or nutrients into my bloodstream. I understand the potential risks, including but not limited to bruising, infection, or allergic reactions. I agree to follow any aftercare advice provided and to notify the practitioner if I feel unwell or experience any unusual symptoms during or after the procedure. *

v v The IV therapy is not a substitute for professional medical advice, diagnosis, or treatment. All treatments are administered by qualified practitioners and are subject to review and approval. I must inform The IV Lounge of any changes to my health status prior to each session. And, by signing, I agree to the treatment voluntarily and accept the potential risks involved. *

v v By checking this box, you consent to our Data Protection Policy: * (HERE)