Ala Carte IV Drip Infusion Menu | IV Drips Bali

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Vitamin C IV
Electrolytes IV
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IV Ingredients
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Vitamin C IV
Electrolytes IV
Medical IV
Ala Carte IV
IV Ingredients
About IV Therapy

Ala Carte IV

Ala Carte Menu

Please choose, combine, and select the ingredients you may want in your custom IV infusion.

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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

Other condition not listed. Please comment…

Where would you like your appointment ? *

Jimbaran
Canggu
Ubud

Infusion Base *

Vitamin B

(IB-3) Vitamins B1-B6-B12 (not more than once per week)
(IB-X) Vitamins B1-B2-B3-B5-B6-B12 (No more than once every 2 weeks)
None

Vitamin D

Vitamin D Injection (Direct injection to body, not IV) (minimum 3 months between doses, Doctor Rx required)
Vitamin D pill (no more than once per week)
None

Minerals

(Choose between MINERALS or EDTA) (Choose max 3 in this category)

Magnesium sulfate 1 cc in 40% solution
Selenium 3 cc (not more than once every 2 weeks)
Silver hydrosol (Doctor prescription only)
Iron 1 cc (CAUTION! Only if prescribed for iron anemia)
Zinc

EDTA / Chelation Therapy

(Choose between EDTA or MINERALS)

EDTA 1/4 gram (Doctor prescription only) (CAUTION! If EDTA is added, can’t add minerals) No Magnesium, No Selenium, No Iron, No Silver Hydrosol

Medicines & Boosters

DMSO (Doctor prescription only)
NAC (not more than once every 2 days)
Lysine

Amino Acids

L-Carnitine (IV bolus administration)
None

Body Enhancement

(Choose max 2 in this category)

ALA – Alpha Lipoic Acid NEW !!
Glutathion
Collagen
Condroitin sulfate

Homeopathic / Base Medicines

(Choose max 2 in this category – BSI Exclusive)

Compound IN (Nigella Sativa)
Compound IP (Soursop)
Compound IL (Mangosteen Pericarp)
Compound IZ (Zingiberaceae)

Brain Booster

Piracetam (Doctor prescription only)

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

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Contact Us

Tel: +62 812 2550 5757

WA: +62 878 6171 7442

service@ivdripsbali.com

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