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IV Drip Intake Form

*Form info

First name

Last name

Email

Phone

Medical History

Heart disease / hypertension

yes

no

Kidney disease

yes

no

Liver disease

yes

no

Diabetes

yes

no

Epilepsy / seizures

yes

no

Asthma

yes

no

Autoimmune disease

yes

no

Blood disorders (anaemia, clotting issues)

yes

no

Pregnancy / breastfeeding

yes

no

Allergies (medication/food/other)

yes

no

Current infection or fever

yes

no

List all current medications, supplements & injections:

Previous surgeries or hospitalisations (last 12 months):

Are you currently undergoing oncology treatment?

yes

no

Have you ever been diagnosed with cancer?

yes

no

Are you currently taking oncological medications?

yes

no

Nature of Services Provided at Plasma-Med

I acknowledge that all treatments provided at Plasma-Med — including but not limited to nutritional support, natural therapies, IV vitamin infusions, hydrogen therapy, biorezonance, detox protocols, and complementary wellness therapies — are supportive in nature.

These services are intended to improve overall well-being, support recovery, strengthen the immune system, and enhance quality of life, but they are not medical cancer treatments.

Medical Supervision

I confirm that:

I remain under the care of my oncologist and/or medical specialist.

I will not stop, delay, or modify any medically prescribed oncology treatment without consulting my doctor.

I have disclosed accurate information regarding my diagnosis, treatments, medications, and supplements consulting my doctor.

Scope of Responsibility

I understand and accept that:

Plasma-Med does not diagnose cancer or monitor cancer progression.
Plasma-Med does not offer medical treatment for cancer.
Therapies may support wellbeing but results vary for each individual.
Plasma-Med practitioners do not make decisions regarding oncology treatment protocols.
Complementary therapies are not intended to cure or treat cancer.

Patient Consent

I declare that:

I have received clear and understandable information about the supportive nature of Plasma-Med services.

I have had the opportunity to ask questions.

I understand the voluntary nature of these therapies.

I consent to receiving complementary/supportive treatments at Plasma-Med.

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IV Drip Intake Form

Nature of Services Provided at Plasma-Med

Medical Supervision

Scope of Responsibility

Patient Consent