[MY B2B] IV Therapy Assessment Form

Patient's Personal Details

Name (as per IC/Passport) :*

NRIC/Passport Number:*

Gender:*

Phone Number:*

E-mail Address:*

Emergency Contact Number & Relationship:*

Emergency Contact Phone Number:*

Address:

1. This assessment is to be filled up by patients upon booking and to be verified by Speedoc before appointment confirmation
2. Speedoc consulting doctor will review for authorisation if there is a tick (✓) in any of the boxes below. Patients will be called directly if there is a need for further medical investigation.
3. Not recommended for pregnant women, individuals with pre-existing medical condition affecting heart, kidney & liver. Extreme of age (below 18 & above 80 years old) and potential difficulty in getting IV line
4. All bookings and payments are handled by Recovery Hub
5. Please tick (✓) if you are diagnosed for any of the medical conditions listed:

Are you and/or have you been diagnosed with:*

PregnantHeart failure or other heart conditionsKidney failure / diseaseLiver failure / diseaseRecent stroke or traumatic head injury (< 6 months)Severe allergy for any nutrients / food / medications. If yes, please state below.Severe medical conditions / other medical conditions. If yes, please state below.Any medical conditions that requires restrictions of fluid / electrolyte / mineral / vitamin. If yes, please state below.

Please select the product purchased:*

IV Sports SingleIV Sports PackageIV Sports Pro SingleIV Sports Pro Package

FREE doctor teleconsultation for you ! Now let's personalize therapy frequency sessions with a doctor via Speedoc App. Follow the steps below to book a slot:

Step 1 Choose your appointment slot below
Step 2 Download Speedoc app and activate your account to get your free doctor consultation

Video Consultation Appointment

I hereby declare and acknowledge that the information provided above is accurate and true. I understand that I am responsible to disclose any medical conditions/concerns for assessment purposes prior to IV therapy administration.*

Patient's Name (as per NRIC / passport):*

Please verify that you are human*

SPEEDOC IV THERAPY ASSESSMENT FORM