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  • Fluturi Vitamin Drip On The GO Please Answer The Following Before We Book You An Appointment

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    Ramos Felipe
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    This document is a health screening form for people interested in receiving intravenous vitamin drips or glutathione injections from Fluturi Vitamin Drip On the GO. It requests the person's name, address, contact information, age, occupation, and payment method. It then asks a series of yes or no health screening questions regarding previous treatments, recent travel, current symptoms, allergies, existing medical conditions, seizures, and pregnancy status. The person must sign at the bottom to confirm their responses.

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    vitamin drip with glutathione

    Original Title

    Fluturi-Vitamin-Drip-On-the-GO

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    This document is a health screening form for people interested in receiving intravenous vitamin drips or glutathione injections from Fluturi Vitamin Drip On the GO. It requests the person's name, address, contact information, age, occupation, and payment method. It then asks a series of yes or no health screening questions regarding previous treatments, recent travel, current symptoms, allergies, existing medical conditions, seizures, and pregnancy status. The person must sign at the bottom to confirm their responses.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    16 views1 page

    Fluturi Vitamin Drip On The GO Please Answer The Following Before We Book You An Appointment

    Uploaded by

    Ramos Felipe
    This document is a health screening form for people interested in receiving intravenous vitamin drips or glutathione injections from Fluturi Vitamin Drip On the GO. It requests the person's name, address, contact information, age, occupation, and payment method. It then asks a series of yes or no health screening questions regarding previous treatments, recent travel, current symptoms, allergies, existing medical conditions, seizures, and pregnancy status. The person must sign at the bottom to confirm their responses.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Fluturi Vitamin Drip On the GO

    Please answer the following before we book you an appointment.


    Name:
    Complete address:
    Contact number:
    Age:
    Work:
    Mode of Payment:
    ☐ Is this your first time having Glutathione or Vitamin Drip?
    ☐ Any travel outside Bataan for past 1 month?
    ☐ Having fever, or any respiratory problems like cough, colds and sore throat?
    ☐ Any allergies on medicines or food? If yes, please indicate.
    __________________________________________________.
    ☐ Do you have maintenance drug? If yes, please indicate.
    __________________________________________________.
    ☐ Are there any known diseases? Is it controlled?
    __________________________________________________.
    ☐ No history of epilepsy or seizure?
    ☐ (For female) Not pregnant?

    Signature

    Fluturi Vitamin Drip On the GO


    Please answer the following before we book you an appointment.
    Name:
    Complete address:
    Contact number:
    Age:
    Work:
    Mode of Payment:
    ☐ Is this your first time having Glutathione or Vitamin Drip?
    ☐ Any travel outside Bataan for past 1 month?
    ☐ Having fever, or any respiratory problems like cough, colds and sore throat?
    ☐ Any allergies on medicines or food? If yes, please indicate.
    __________________________________________________.
    ☐ Do you have maintenance drug? If yes, please indicate.
    __________________________________________________.
    ☐ Are there any known diseases? Is it controlled?
    __________________________________________________.
    ☐ No history of epilepsy or seizure?
    ☐ (For female) Not pregnant?

    Signature

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