IV Therapy Booking

Upon Completion of Form, An IV Therapist Will Contact You Within a Few Minutes for Confirmation. We Pride Ourselves on Fast Response Times. Have an IV Therapist at Your Location Within 2 Hours!

Full Name*

First NameLast Name

Address Of Appointment *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Appointment Time and Date (click Asap Below for First Available)

ASAP

Number of People (Not Sure? More Can Be Added if Needed)*

Is Anyone Currently Pregnant?*

YesNo

Does Anyone Have History of Congestive Heart Failure, Decreased Liver or Kidney Function or Undergoing Chemotherapy?*

YesNo

Allergies to Any Medications or Supplements?*

I hereby authorize the staff at Coastal Wellness Mobile IV to administer either IV and/or IM therapy. I have made known to Coastal Wellness staff of any medical history, medications, allergies or past reactions that may interfere with therapy

I understand that these therapies involve inserting of a needle/catheter into either the vein or muscle. I understand that it is my responsibility to notify the staff of any burning, pain, or adverse reaction that I may be experiencing. I understand that with IV therapy it is possible that if the catheter becomes dislodged or infiltrated that it may cause swelling, pain or discomfort at the site however, this is not dangerous to me or my health and that the fluids will absorb and the swelling and tenderness will subside
Benefits:Immediate rehydration, replacement of vitamins, minerals, amino acids, nutrients, and antioxidants that are available immediately via the bloodstream to the tissue.
Injectables are not affected by stomach or intestinal disease.
Higher doses of nutrients can be given than possible by mouth without intestinal irritation.
I understand that there is no implied or stated of guarantee of success or effective of any specific treatment.Pain, discomfort, bruising at the injection site (occasional)
Infection, swelling at phlebitis at the site (rarely).
Injectables are not affected by stomach or intestinal disease.
Severe allergic reaction, anaphylaxis, infection, cardiac arrest or death (rarely)
Alternatives to IV/IM therapy include oral supplementation, lifestyle and dietary changes I am aware that unforeseeable complications could occur and that Coastal Wellness mobile IV staff is not an ambulance service nor equipped to handle life-threatening emergencies. If the event of any unforeseen severe reaction, 911 will be notified. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV/IM therapy.
OUR PRODUCTS AND SERVICES ARE NOT A TREATMENT FOR ANY SERIOUS MEDICAL CONDITIONS

IV Therapy Appointment Booking