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Infusion Base

Patient Name

Please give accurate information so you are not confused with other patients

Date of Birth (d/m/y)

Email

We respect your privacy. Your address will not be given to anyone without your permission. Please note that all correspondence will be via these addresses. Please be sure you can receive email from medical@bsi.international (there is no .com etc.)

Email

Confirm Email

Phone

We respect your privacy. BSI does not give personal information to outside parties. We request contact info in the event of schedule changes or emergency situations

Requested Day & Time

IMPORTANT, Please note: we will do our best to give you the requested time slot. Confirmation will be sent via WA or Email.

Date

Time

Important medical questions

I have pain in the kidneys
I have hot or burning urine
I have a blood-related disease or frequent bleeding
I am anemic
(If female) I am pregnant or breast feeding
(If female) I am presently menstruating
I have or have been treated for cancer
None of these

Sorry, if pregnant or breast feeding, we can only offer Vita Basic or Vita Booster.
Please choose below

Layout

Other condition not listed. Please comment...

Where would you like your appointment ?

Talk to Practitioner

I need to talk with a BSI Practitioner before my IV. (A very short consultation is free). There may be a short wait if the doctor or nurse practitioner is with another patient.

Total

Rp. 0

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