Refuel Global — Doctor-Led IV Therapy, Delivered

Part A

Patient Information

Step 1 of 3

Full Name

Full name is required.

Date

Date of Birth

Date of birth required.

Age

Gender

Male

Female

Other

Please select gender.

WhatsApp / Phone

+91

Valid 10-digit number required.

Email

Valid email required.

Emergency Contact — Name

Emergency contact name required.

Emergency Contact — Phone

+91

Valid 10-digit number required.

Address / Property Location (for concierge visit)

Please provide your address.

Drip / Session Requested

Please select a drip.

Visit Date & Time

Please select visit date & time.

Part B

Medical History

Step 2 of 3

Other conditions not listed (optional)

Medication Allergies (optional)

Other Allergies (food, latex, etc.)

Current Medications & Supplements (optional)

Have you received IV therapy before?

Yes

No

Please select an option.

If yes — where and when?

Any adverse reactions to previous IV?

Yes

No

Please describe the adverse reaction

Lifestyle

SMOKER

Yes

No

ALCOHOL

Occasional

Regular

None

EXERCISE

Daily

Weekly

Rarely

Reason for today's session / health goals

Please describe your session goals.

Part C

Informed Consent

Step 3 of 3

Please read each statement carefully and check the box to indicate your understanding and agreement.

Patient Full Name (print)

Please print your full name.

Date

Patient Signature

Sign with mouse or finger

Please provide your signature.

If patient is under 18, parent/guardian signature is required. Please note the guardian's name in the signature area and bring signed physical consent on the day.

Elevated wellness.
Delivered to you.

Five ways to refuel

The Refuel Quiz

Your Vitality Snapshot

Recovery-Leaning

Before your first session

Simple, clinical, at home

Health intake

Physician approval

Nurse arrives

Your drip, ~45 min

Inside Refuel

Care led by a registered doctor

Dr. Taleebuddin Syed

See Refuel in action

One membership. That’s it.

Book your session

Ready to refuel?

Elevated wellness.Delivered to you.