Patient details

Emergency contact

Medical disclosure

Tick anything that applies. Leave blank if it does not.

Possible risks and side effects

I understand that IV therapy may carry the following risks:

• Bruising or pain at the IV site
• Dizziness or lightheadedness
• Infection
• Allergic reaction
• Extravasation (fluid leakage into surrounding tissue)
• Headache, nausea, or flushing
• A temporary metallic taste in the mouth
• Rare risk of fluid overload or electrolyte imbalance

Client acknowledgement

By signing below, I confirm that:

Emergency & financial consent

• I authorise The Wellness Nest to provide emergency care if required
• I authorise contact of emergency services if clinically indicated
• Payment is required directly after treatment
• Once IV therapy has commenced, a no-refund policy applies — all compounds and minerals will have been prepared and used

Signature

Sign in the box below using your finger or stylus.

Draw your signature above