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Wellness IV 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):

Have you ever been diagnosed with cancer?

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 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 offer medical treatment.
Therapies may support wellbeing but results vary for each individual.
Plasma-Med practitioners do not make decisions regarding treatment protocols.
Complementary therapies are not intended to cure.

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.

Signature

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Wellness IV Intake Form

Nature of Services Provided at Plasma-Med

Medical Supervision

Scope of Responsibility

Patient Consent