Smoking Cessation Program | BSI International Clinics

IV Infusion Series

Please choose one or all package

Day 1 : Brain & Nerves
Day 8 : Strength & Stamina
Day 16 : Anti-Aging & Bones
Day 24 : Skin & Immunities

Day 1 : Brain & Nerves

1 gram of Vitamin C
2 grams of Vitamin C
3 grams of Vitamin C

Day 8 : Strength & Stamina

1 gram of Vitamin C
2 grams of Vitamin C
3 grams of Vitamin C

Day 16 : Anti-Aging & Bones

1 gram of Vitamin C
2 grams of Vitamin C
3 grams of Vitamin C

Day 24 : Skin & Immunities

3 grams of Vitamin C

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 / WhatsApp

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

Where would you like your appointment ?

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

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...

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.

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Total

Rp. 0

Smoking Cessation Program – Doctor In-Clinic Services

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