IV Me Now FL - Medical History & Contact Information

IV Me Now FL - Medical History & Contact Information
Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Driver's License #*
Driver License State of Issue*
Address
Street Address*
City*
State*
Zip Code*
Medical Information
Emergency Contact Full Name*
Physician Full Name*
Physician Phone Number*
Height*
Feet (') and Inches(")
Weight*
in lbs
Please list any drug allergies you have*
Please list any medications you currently take*
Have you had any previous surgeries or procedures?*
Have you experienced any decrease in sex drive or libido?*
YesNo
Additional information about your chronic medical condition.
How many hours a week do you exercise?
Have you had any problems sleeping?*
YesNo
YesNo
YesNo
YesNo
The following questions are for those ordering Semaglutide or Tirzepatide.
Currently pregnant or plan to become pregnant in the next year?Currently breastfeeding?Currently being treated for cancer?Active or history of eating disorder?Active gallbladder disease?Active substance abuse or dependency?Type 1 diabetes?Bariatric surgery? (within the past 18 months)Pancreatitis within the past 6 months or history of pancreatitis caused be taking GLP-1?History of medullary thyroid cancer/MEN syndrome of family, history of either of these?
Please read and confirm you understand the Statement of Patient:
By purchasing products from IV Me Now, you understand that results are not guaranteed, and individual outcomes may vary. You assume full responsibility for any risks, including potential side effects or interactions with other medications. IV Me Now, is not liable for any adverse reactions or health issues that may arise from the use of these products. Please read about the possible side effects of both tirzepatide and semaglutide prior to purchasing.

We strongly recommend that you see your primary care physician (PCP) regularly and inform them of any medications or treatments you are receiving from IV Me Now. It is important to be monitored by your PCP to ensure the safe and effective use of these products. If you experience any issues, please contact us directly.

By filling in this form, I consent to receiving marketing communications via email, text messages, or other methods from IV Me Now. I understand that I can opt out at any time.

All sales are final, and no refunds or returns will be accepted. By completing your purchase, you confirm your agreement to these terms and conditions.
All submissions reviewed by our physician, Dr. Angelo Asheh MD
I have read and understand the above statement
Email*
example@example.com
The patient’s medical history will be discussed via phone or telehealth with a licensed healthcare provider prior to the approval and dispensing of any medication. All medical histories are carefully reviewed to identify any potential contraindications, interactions, or side effects before the medication is approved and delivered.
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IV Me Now FL - Medical History & Contact Information

Personal Information

Address

Medical Information

The following questions are for those ordering Semaglutide or Tirzepatide.

Please read and confirm you understand the Statement of Patient:

All submissions reviewed by our physician, Dr. Angelo Asheh MD