The IV Hub Patient Enrollment Form

Name

First NameLast Name

Date

MonthDayYear

Date of Birth

MonthDayYear

Phone Number:

Format: (000) 000-0000.

E-mail

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In case of emergency

Emergency Contact:

First NameLast Name

Relationship

Contact Number

Format: (000) 000-0000.

Weight (pounds)

Height (inches)

Taking any medications, including herbal supplements currently?

YesNo

Are you on a blood thinner?

YesNo

Do you have any Allergies to medications?

YesNo

What service are you interested in? Weight Loss or IV therapy? Please list all your questions here:

What is your past medical history?

Have you been diagnosed with congestive heart failure or coronary artery disease?

Have you been diagnosed with liver disease?

Have you been diagnosed with diabetes?

Have you been diagnosed with kidney disease

Any history of GI bleeding?

Are you pregnant or breastfeeding?

Please be advised that if you answered yes to any of the 6 questions, you may be denied services for safety reasons

What Treatment Are you Interested in Today?

1. Immunity: 1 liter of normal saline, Vitamin C 500 mg, Vitamin Complex and Zinc2. Inner Beauty: 1 Liter of normal saline, Vitamin Complex, and Biotin3. Hangover: 1 liter of normal saline, Vitamin and Mineral complex, and Zofran (nausea)4. Recovery and Performance: 1 Liter of normal saline, Vitamin C, vitamin and mineral complex, and amino acid blend5. Vitamin B12 Intramuscular Injection 1000 mcg (NOT ALLOWED if allergic to Sulfa or Cobalt)*IMPORTANT: Vitamin C infusions are NOT ALLOWED 7 Days before Surgery6. Migraine Relief: 1 Liter of normal saline, Zofran for nausea and Toradol for pain

Terms and Conditions Accepted