Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
What is your current weight?
*
How tall are you?
*
Address where we should come to give you your IV infusion or other service.
*
Full street address, and town. Please include any extra details that will help us locate you.
Phone number where we can call or text you
*
(###)
###
####
How did you hear about us?
*
Which service are you interested in?
*
Do you have any existing health issues?
*
We will complete a more thorough medical history in person, but please briefly describe any health issues you have, medical diagnoses you've received, and major surgeries you've had.
What surgeries have you had in the past?
*
What medications, drugs, and supplements are you currently taking?
*
Anything that you are regularly or semi-regularly taking, including prescription, over-the-counter, recreational, vitamins, and other supplements.
Females: Are you currently pregnant or breastfeeding?
How will you pay?
*
Due at time of service. We accept cash, major credit cards, and FSA and HSA cards. We can also provide a detailed receipt for healthshare purposes, if needed. Sorry, we are not able to accept health insurance.
Thank you for submitting your form! We will text you shortly to confirm when and where we can meet you for your IV infusion.
If you don't hear from us within the hour, we are unexpectedly out of cell service range, or facing other unforseen circumstances, and will get back to you as soon as possible.
Remember, if an order is completed during the night, a nurse will contact you the following morning.
