HOCATTTM Assessment/Registration Form Surname(Required) First name(s)(Required) Preferred name Gender Male Female Gender neutral Other TitleMrMrsMissMasterMsDrProfDate of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home address Street Address City ZIP / Postal Code Postal address (if different): Contact DetailsHomeWorkMobile(Required)Email Address(Required) Next of Kin Name Emergency Contact Details G.P. Name Medical Centre Height Weight Occupation Previous illness/surgeries(Required)Current health concerns (what brings you to IV Boutique?):(Required)There are certain conditions where certain modalities should not be used. Please answer the questions below. Do you or have you ever had- Yes/NoRecent fever(Required) Yes No Heat insensitivity(Required) Yes No Low blood sugar levels(Required) Yes No Uncontrolled high blood pressure (BP)(Required) Yes No Low blood pressure(Required) Yes No Taking BP medication(Required) Yes No Pregnancy(Required) Yes No Active bleeding (injury)(Required) Yes No Bleeding tendencies e.g. haemophiliacs/ Von Willebrands etc(Required) Yes No Known heart conditions e.g. heart failure, recent MI, arrhythmias etc.(Required) Yes No Blood clots e.g. DVT/PE/CVA(Required) Yes No Surgery in last 72 hours(Required) Yes No Broken, injured, swollen, inflamed or infected skin on hands or feet(Required) Yes No Cancerous or malignant tissue(Required) Yes No Epilepsy or seizures(Required) Yes No Electrical implant e.g. pacemaker, cochlear implants, insulin pump, or any internal device that works with batteries (electrical energy)(Required) Yes No Implanted metals e.g. pins, plates, screws, joint replacement, mechanical heart valves, metal stents etc.(Required) Yes No G6PD deficiency(Required) Yes No Thyrotoxicosis/Hyperthyroidism(Required) Yes No Cutaneous porphyria(Required) Yes No Vitiligo(Required) Yes No Do you have any allergies?(Required)Current medications, including herbs and supplements:(Required)Are there any other medical conditions your practitioner should be aware of? YES/NO(Required) Yes No Please Note:It is very important to drink plenty of water before and after a HOCATTTM session, as well as throughout the rest of the day. Drinking water helps your body to flush out toxins. Detoxifying the body too fast can overload the bodies’ avenues of elimination. Overloading can result in a detox reaction or “cleaning crisis”. You could experience anything from flu-like symptoms to a skin rash. This is why at IV Boutique we start low, slow, and build up each session and why you should drink plenty of water! Thank you for completing the Registration form, one of our Registered Nurses will be in touch to talk you through the amazing benefits, the process and make a booking if you haven’t already! NameThis field is for validation purposes and should be left unchanged.
