Letz Drip

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Consent Form

This form helps us understand your health status to ensure safe and effective treatment. Please answer all questions honestly. All information will be kept confidential.

Client Name
Gender

1. Service/ Treatment Details

Please indicate the service(s) you are receiving:

2. Explanation/Purpose of Procedure

• IV Drip: Infusion of vitamins, minerals, and fluids to support hydration, wellness, and recovery.
• Vitamin Injection: Administration of vitamins and nutrients via injection for health and wellbeing.
• Blood Test: Collection of a small blood sample for monitoring, diagnostic, or health assessment purposes.

3. Risks & Potential Side Effects

• IV Drip: Mild bruising, soreness, redness at injection site; dizziness or light-headedness; rare infection or vein irritation.
• Vitamin Injection: Pain, redness, swelling at injection site; mild allergic reaction; rare systemic reaction.
• Blood Test: Mild bruising or soreness; fainting or dizziness; rare infection or reaction to antiseptic.

5. Lifestyle Information

Smoking:
Alcohal
Lifestyle:

6. Treatment Goals / Desired Outcomes

7. Service-Specific Screening Questions

• IV Drip: Recent illness, vein issues
• Blood Test: Recent infection, blood disorders, consent to sample storage
• Vitamin Injection: History of injection reactions, current medications
• Do you have a preferred arm or vein for administration?

8. Staff Assessment

Staff member to review client responses and assess suitability for treatment:
IV Drip:
Blood Test:
Vitamin Injection:

9. Acknowledgment & Understanding

I understand:
The purpose, procedure, benefits, and risks of the selected service(s). These services are not a substitute for medical care. I may withdraw consent at any time

10. Consent & Declaration

I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that withholding medical information may increase the risk of adverse reactions during or after treatment.

Clear Signature
Clear Signature

Confidentiality Notice:

All personal and medical information is treated as confidential in accordance with GDPR and CQC Information Governance Standards. This form will be securely stored in your client file and used only for treatment and safety purposes.