REFUEL
IV Wellness · Hyderabad · Concierge Therapy

Patient Intake & Consent Form

Complete all three sections before your first session. This record is kept confidential.

Confidential Medical Record
A · Patient Info B · Medical History C · Consent
Part A
Patient Information
Step 1 of 3
Full name is required.
Date of birth required.
Please select gender.
+91
Valid 10-digit number required.
Valid email required.
Emergency contact name required.
+91
Valid 10-digit number required.
Please provide your address.
Please select a drip.
Please select visit date & time.
Part B
Medical History
Step 2 of 3
Please select an option.
SMOKER
ALCOHOL
EXERCISE
Please describe your session goals.
Part C
Informed Consent
Step 3 of 3
Please read each statement carefully and check the box to indicate your understanding and agreement.
1. Nature of TreatmentI understand that IV therapy involves inserting a cannula into a vein for direct administration of vitamins, minerals, fluids, and compounds. Sessions are administered by trained medical professionals under clinical protocols.
2. Risks & BenefitsI have been informed of potential risks including bruising, phlebitis, infection at the cannula site, allergic reactions, dizziness, nausea, or in rare cases more serious systemic reactions. I accept these risks voluntarily.
3. Accuracy of InformationI confirm all health information provided in this form is accurate and complete. I understand that withholding medical information may compromise my safety during treatment.
4. Right to WithdrawI may withdraw consent and request the infusion be stopped at any point during treatment without any obligation to continue.
5. Emergency CareIn the event of an adverse reaction, I consent to emergency medical care being sought on my behalf, including contacting emergency services (108 / relevant authorities).
6. Data & PrivacyI consent to Refuel IV Wellness (Rejuvia Health Pvt. Ltd.) storing my health records securely and confidentially per applicable Indian data protection legislation. Records will not be shared with third parties without my explicit consent.
Please print your full name.
Sign with mouse or finger
Please provide your signature.
If patient is under 18, parent/guardian signature is required. Please note the guardian's name in the signature area and bring signed physical consent on the day.