IV/ Injection
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Allergies or n/a
I am NOT allergic to Sulfa drugs
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I think I currently have Covid. Yes or No.
Visits for vitamin injections/IVs are not billed under insurance. You may use a HSA card but the office cannot guarantee the services will be covered. The office will NOT write a letter of medical necessity if one is needed by your HSA plan.
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I understand.
Vitamin injections and infusions are not FDA approved. Customized Wellness cannot guarantee any specific results.
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I understand.
There is no data from the FDA that any type of vitamin taken orally, injection or infusion will help your immune system. Getting an IV or injection for your immune system does NOT mean you will not contract influenza, Covid 19 or any other communicable disease.
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I understand.
I am asking for a vitamin injection or infusion from Customized Wellness. I have not met with a provider for specific recommendations. I accept all responsibility for any reaction I may have.
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Vitamin D is a fat soluble vitamin and although rare you can become toxic if too much is taken. If you would like to get frequent injections of vitamin D you will need to get blood levels tested.
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I understand.
Although vitamin infusions and injections are typically safe one could have a reaction to any of the ingredients. In the event of an emergency the office will call 911.
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Any history of kidney or liver disease? If yes what kind? or n/a
Any history or heart or vascular disease?
Any history of allergies or asthma?
Do you carry an epi pen? If so for what?
Are you on a blood thinner?
Do you have an auto-immune disease? If so, which one?
Persons with a uterus, when was your last menses? or type n/a
List ALL medications/ dose and REASON for taking or n/a
List ALL supplements or n/a:
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I hereby consent to treatment at Customized Wellness, LLC and attest that my answers are true.
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Please type why you are seeking IV/Injections and list the one(s) you are interested in.
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