IV Therapy Hydration
Place of lodging must be within 12 miles from Doctors office
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Place of lodging
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parking Instructions
Phone Number
*
E-mail
example@example.com
IG handle
Procedure type
*
Date of Surgery
*
-
Month
-
Day
Year
Date
Post Op date
*
-
Month
-
Day
Year
Date
Any allergies to food or medication
*
Past medical history
*
Signature
Clear
My Products
*
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IV Therapy Pay in Full
$50 cancellation fee
$
250.00
Quantity
1
2
3
4
5
6
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8
9
10
Iron Infusion
$
350.00
Quantity
1
2
3
4
5
6
7
8
9
10
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