IV Drip Consent

Informed Consent for IV Treatment:

You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Procedure involves inserting a needle into your vein and infusing a mixed formula of vitamins and minerals. Alternatives to Intravenous Therapy is oral supplementation and/or dietary and lifestyle changes. Risks of Intravenous Therapy include discomfort, bruising and pain at the site of injection, inflammation of the vein used for injection (phlebitis), severe allergic reaction, anaphylaxis, cardiac arrest, and death. Benefits of Intravenous Therapy include: 100% absorption of infused vitamins and minerals, total amount of infusion is available immediately to the tissues, nutrients are forced into cells by means of a high concentration gradient, higher doses of nutrients can be given than possible by mouth, without intestinal irritation.

Have you received IV Therapy before?

Please tick if you have any of the following conditions that IV Therapy can help with

Any abnormal results from blood test?

Do you have any medical devices implanted in your body? Pins, Plates, Pacemakers?

Please tick if you have any of the diagnoses below:


I consent to acting as a model for the purpose of training (under supervision) in the administering of Iv Therapy. The use and indications for the products that I will be treated with have been explained to me by the practitioner and I have had the opportunity to have all my questions answered to my satisfaction. I have answered the questions regarding my medical history to the best of my knowledge. 

Training course times may be delayed due to unforeseen circumstances. It may take longer training the students or the student may need more support. So please allow extra time in case this event occurs. Your full payment for your treatment as a model is non-refundable. If the circumstances occur outlined above and/or cancellation your payment is non-refundable. The full payment will be made prior to attending the training academy.

Every procedure involves a certain amount of risk and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although most patients do not experience these complications, you should discuss each of them with your practitioner to ensure you understand the risks. Potential complications and consequences of IV Therapy.

I consent to Ampika’s Aesthetics using photographs being stored on a training file and be used for social media purposes photographs and/or video recordings including images of me both internally and externally to promote the Training Academy. These images could be used in print and digital media formats including print publications, websites, e-marketing, posters banners, advertising, film, social media, teaching and research purposes. I understand that images on websites can be viewed throughout the world and not just in the United Kingdom and that some overseas countries may not provide the same level of protection to the rights of individuals as EU/UK legislation provides. I understand that some images or recordings may be kept permanently once they are published. I have read and understand the conditions and consent to my images being used as described.

I am signing to consent to my treatment being administered at Ampika’s Aesthetics. On behalf of the training academy Ampika’s Aesthetics - Ampika’s Hair Make Up and Beauty. You are agreeing to be a model and hold no responsibility towards Ampika’s Aesthetics for any procedures that may incur any personal dissatisfaction or cause of concern.

Any models wishing to seek any legal or liable action will not be permitted to do so once signing this disclaimer you are excepting full responsibility to allow a student to carry out your injectable treatments.

We are a training academy providing our students with a module in which they facilitate live models in order for each student to get accreditation in the relevant service. 
Medical professionals who observe the students have the right to refuse models who aren’t suitable for a treatment. This would be at their discretion.
We do not support any negative comments on social media or any other rating platforms as you will be refused entry to obtain any further treatments with Ampika’s aesthetics training academy at any one of our locations .

These Students who are responsible for carrying out the treatment under medical supervision, are not fully qualified to carry out Iv Therapy unassisted. Therefore, you understand the risk that this may pose. Any concerns must be addressed whilst you are present in the training academy. Whilst all the trainers accommodate you to ensure you are fully satisfied with your treatment, we are unable to rectify problems weeks after you have undergone the treatment. If there are any concerns then please contact the training academy within 48 hours of treatment via email at [email protected].

By signing this form you have agreed to consent to adhere to our vaccination policy.

I consent I have read and understood the aftercare sheet which has been provided to me

The information that I have given is correct to the best of my knowledge.

I have not knowingly withheld any medical information

I consent to the treatment described.



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Signed by Ampika Pickston
Signed On: June 9, 2021

Signature Certificate
Document name: IV Drip Consent
lock iconUnique Document ID: 2643f2bf5aa073a32110782e52ac7fc486c654eb
Timestamp Audit
November 23, 2020 11:03 am BSTIV Drip Consent Uploaded by Ampika Pickston - [email protected] IP 2a00:23c4:600b:6200:ecb0:e2cc:50f1:3510
February 1, 2021 9:50 am BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:c553:e3b7:94b6:6079
March 24, 2021 2:24 pm BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:6d1f:26d0:f128:fda8
May 17, 2021 2:32 pm BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:8c91:4647:3701:7107