IV Therapy Appointment

IV Therapy Appointment

Upon completion of this form, a member of the CWNC management team will contact you within a few minutes for confirmation and to gather further information. We pride ourselves on fast response times. Have an IV Therapist at your location within 2 hours!
Please do NOT use this form to schedule a telehealth appointment for weight management consults. Our Nurse Practitioner will reach out to you within 24-48 business hours after submission of your Health and Wellness Consult form at the phone number you have provided. She will set up an appointment with you directly. This form is ONLY for making an IV therapy appointment request. If you have any questions, please contact us at 888-313-3165 by call or text. Thank you!
I understand that once I schedule IV therapy services I will be sent an IV/IM Therapy Consent Form to complete prior to the time of appointment.
I understand that Coastal Wellness NC has the right to refuse services to anyone should their assessment reveal a medical concern and/or contraindication.
I understand that if more than one person is receiving services, each person will have to complete their own IV/IM Therapy Consent Form.
I am aware that this form is HIPPA compliant and will only be used for the purpose of review during phone consultation to set up the appointment. This information will not be shared with anyone outside of my healthcare team unless a release of information form has been completed and signed granting permission.
Name of person requesting appointment:

First NameLast Name
Preferred Nickname, if applicable:
Preferred Pronouns:
Date of Birth (must be over the age of 18 yo to make an appointment request) :

MonthDayYear
Date
Are you requesting an appointment for services at our storefront location in Arden, NC?
Please provide the address of where you’d like to be seen for your appointment (we currently provide services in Western North Carolina Counties) :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (please be available for contact to provide more detailed intake information) :
Please enter a valid phone number.Format: (000) 000-0000.
Email Address :
How did you hear about Coastal Wellness NC?
If you have a preferred nurse or medic, add their name here please :
Promo Code from website and/or social media if applicable :
The schedule below provides selection for our regular week day business hours. We do have limited coverage for after hours calls and we do have weekend hours available. Please be aware that while we do NOT charge a mobile fee, an after hours fee of $50/hour may apply after 7:00 pm Monday-Sunday.
Appointment Date and Time (Click ASAP below for first available OR after hours requests) :
ASAP :
Is this a request for a single, individual IV appointment? (may select more than one)
What symptoms are currently being experienced that led you to seek out IV hydration therapy?
Have you, or someone within your household tested positive for flu, RSV, or Covid within the last 10 days?
Are you, or anyone seeking services currently pregnant?
Do you, or anyone seeking services have history of congestive heart failure, decreased liver or kidney function, or are currently undergoing chemotherapy?
Should be Empty:

IV Therapy Appointment

The schedule below provides selection for our regular week day business hours. We do have limited coverage for after hours calls and we do have weekend hours available. Please be aware that while we do NOT charge a mobile fee, an after hours fee of $50/hour may apply after 7:00 pm Monday-Sunday.