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Consent and non-liability

You are about to undergo an intravenous infusion of vitamins, electrolytes, trace elements and sodium chloride under the supervision of Dr Ayoun Gilles, 

Please read the information leaflet you have been given carefully, so that you are aware of the conditions for intravenous infusion.

It is imperative that you are fully aware of all the constraints involved in the infusion procedure.

This information is not intended to worry you, but simply to enable you to make a free and informed decision. You have been informed of the benefits you can expect from this infusion risks and possible alternatives.

We remain at your disposal for any further information you may require.

As you have asked me to do, I am pleased to sign below to certify that I understand and accept the following :

 I have read and understand the medical disclaimer.

 I acknowledge that Inifinite-Drip can neither guarantee nor be held responsible for the result.


 I certify that I have completed the medical examination form with accurate information to the best of my knowledge.


 I confirm that you have informed me of the risks inherent in this infusion, such as pain at the injection site, bleeding, bruising or hematomas. In addition, there is a certain percentage of

complications, including life-threatening risks arising not only from the procedure itself, but also from unpredictable reactions such as allergies.


 I also acknowledge that I have been able to ask you all the questions concerning this perfusion and that I have taken note of them,

in addition to the aforementioned risks, that there is an unpredictability of duration, aspects and different forms such as vascular fragility, allergic reaction, difficulty in healing, etc.; as well as exceptional, even unknown risks.


 I certify that you have informed me of the expected benefits of this perfusion and of the therapeutic alternatives.


 I can confirm that the explanations you have given me have been clear enough to enable me to make my decision and ask you to carry out this intravenous infusion.


 I expressly undertake to comply with all the care and recommendations you may prescribe for me pre- and post-infusion.

Certify that I have read all the information concerning the prescribed intravenous infusion:

 carried on :        




signature (preceded by "read and approved")

Merci pour votre envoi !

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