FUSION WELLNESS CLUB

New Client: YES / NO

INFORMED CONSENT

I that undersigned below:

Full Name :________________________________________________________________
Date of Birth :________________________________________________________________
Gender : Male / Female*
Phone Number :________________________________________________________________
Email :________________________________________________________________
Address :________________________________________________________________
History of Allergies :________________________________________________________________
Truly stating has given

AGREEMENT

To do medical action in the form of infusion.

Again myself / child / wife / husband / father / mother*. I am with
Name :________________________________________________________________
Date of Birth :________________________________________________________________
Number medical records:________________________________________________________________
The purpose, nature and necessity of medical action mentioned above, as well as the risks that can be
caused and efforts to overcome them have been adequately explained by the doctor and I fully
understand.
Thus I make this agreement with full awareness and without coercion.

Badung, Date____Month____________Year______

Doctor/Nurse Who make a statement

Sign Sign

_____________________ _____________________

Witness from the clinic Witness from Patient’s

Families
Sign Sign

*circle the answer and cross out the unnecessary

 FUSION WELLNESS CLUB
New Client: YES / NO

_____________________ _____________________
NURSES PROGRESS FORM

Name :_____________________________________
DOB/Age :_____________________________________
Address :_____________________________________
Gender/Sex :_____________________________________

Date & Time Progress Sign

*circle the answer and cross out the unnecessary

 FUSION WELLNESS CLUB
New Client: YES / NO

*circle the answer and cross out the unnecessary