Intravenous Coctel IV | Beauty Esthetics By Diana Sanchez

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Coctel IV

First Name *

Last Name *

Birthday *

Address *

ZIP *

Phone *

Age *

Sex *

Email *

In case of emergency, contact to:

Name *

Phone *

Where did you hear about beautyesthetics? *

What are your main complaints? *Fatigue or low energyBad diet due to busy lifestyleMental confusion or difficulty concentratingBad mood or depressionCold or flu symptomsFacial wrinkles or fine linesDry or dull skinMalabsorption problemsOther(PLEASE CHECK ALL THAT APPLY)

Which statements best describe why you are here today? *I want to have more energy and feel better in general.I want to do everything I can to nourish my body.I want to do everything I can to improve my weight loss efforts.I want to avoid getting sick.I want to recover quickly from my surgery or illness.I want to delay the aging process.I want to have smoother, brighter and more vibrant skin.I want to recover quickly from a hangover.Other.(PLEASE CHECK ALL THAT APPLY)

Are you pregnant or breastfeeding? *YESNO

If yes, please indicate the frequency:

Consume alcoholic beverages? *YESNO

How many alcoholic drinks do you consume in a week?

Use recreational drugs? *YESNO

If so, which ones and how often?

List everything you are currently taking:

Prescription medications:

Concentration:

Frequency-Condition being treated:

Over-the-counter medication:

Concentration – Frequency:

Disease being treated:

Vitamins and other supplements:

Strength – Frequency Condition to be treated:

Do you take digoxin (Lanoxin) for a heart problem? *YESNO

Do you take diuretics or water pills? *YESNO

If yes, please indicate:

¿Do you take steroids i.e. prednisone? *YesNo

If yes, please indicate:

Have any allergies to any medications or foods? *YesNO

If yes, please indicate:

Date of last laboratory test: *

Have you ever been told that you have an electrolyte imbalance or other abnormal lab tests? *Hypermagnesemia (high magnesium levels)Hypercalcemia (high calcium levels)Hypokalemia (low potassium levels)Hemochromatosis (high iron levels)Other(Please check all that apply)

¿Are you a smoker? *SINO

¿Are you diabetic? *SINO

You have any of the following conditions?Blood pressure problems (high or low)Heart problemsStroke or «mini stroke»Renal problemsAsthmaSickle cell anemiaG6PD deficiencySarcoidosisParathyroid problems (high levels)(Please check all that apply)

Please mention any other medical conditions you have (not mentioned above):

List of all surgical procedures you have had with approximate dates:

CONSENT FORM FOR INTRAVENOUS NUTRIENT THERAPY

This document is intended to serve as informed consent for your intravenous nutrient therapy. Please initial to indicate that you have been informed about:

I have informed the provider of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the provider of my medical history. *

Intravenous infusion therapy and any statements regarding these infusions have not been evaluated by the U.S. Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease… These intravenous infusions are not a substitute for medical care from your doctor. *

I understand that intravenous nutrient therapy is only for healthy adults under 60 years of age. *

I understand that I have the right to be informed about the procedure, any feasible alternative options and the risks and benefits. The procedures are not performed until I have had the opportunity to receive such information and give my informed consent *

Entiendo que:

1. The procedure involves inserting a needle into a vein and injecting the selected solution.

2. Alternatives to intravenous therapy are oral supplementation and/or changes in diet and lifestyle.

3. Risks of intravenous therapy include, but are not limited to:

a) Occasionally: discomfort, bruising and pain at the injection site.

b) Rarely: inflammation of the vein used for injection, phlebitis, metabolic disorders and injuries.

c) Extremely rare: severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.

4. The benefits of intravenous therapy include:

a) Injectables are not affected by stomach or intestinal absorption problems.

b) The total amount of infusion is available to the tissues.

c) Nutrients are introduced into cells through a high concentration gradient.

d) Higher doses of nutrients than possible can be administered orally without intestinal irritation.

Inicials *

I am aware that other unforeseeable complications could occur. I do not expect the provider to anticipate or explain all risks and possible complications. I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered. *

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its completion. *

My signature on this form affirms that I have given my consent for Intravenous Nutrient Therapy, including any other procedures that, in the opinion of my physician(s) or another associated with this practice, may be indicated.

Consentimiento Medico *

I agree that all of the above medical information is true and complete. I agree to the privacy policy and terms and conditions.

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I would like your permission to use these photos for advertising. For example: portfolios, online and print ads, etc. Your consent is necessary regarding this.

With your signature if you would like your photos used or not used in advertising.

We also like to tag our clients in photos used on our Instagram profile!

Please indicate if you’d like to allow this or not below:

May we use the audiovisual content of your session? *

Can we tag you on instagram? *

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