Infusion Booking Form

Please Enter Your Information Below
Name*

First NameLast Name
Email*
example@example.com
Mobile Phone:*
Please enter a valid phone number.
Treatment State:*

Street Address

Street Address Line 2

City

Zip Code
Who will be receiving treatment from MIVM?*

SelfSomeone else
The information entered on this form must reflect the person that is going to be receieving treatment by Mobile IV Medics

Please verify the client's information (person receiving treatment) is entered above and that persons information is entered subsequently for the resepective questions on this form
Is the person to be receiving treatment's information entered in fields above (Name, Email, Phone)?*

NoYes, the person receiving treatment's information is entered above
You have indicated that the information entered on this form is someone other than the person to be receiving treatment. The information entered on this form must be for the client. Please update the Name, Email, and Phone Number above to reflect the client's information

Failure to do so will result in delays and/or denial for treatment
gclid
fbclid
msclkid
gacid
utm_source
utm_medium
utm_content
utm_term
utm_campaign
Ref

When would you like to request your appointment?*

Scheduled date/timeAs soon as possible (ASAP)
We will try our best to take care of you as soon as possible! Our standard hours of operation are 8AM to 8PM, 7 days a week, but we may be able to help you during off hours.

Please be on the lookout for communication regarding your appointment scheduling shortly.
Current Day/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Preferred Appointment*
Treatment Address*

Street Address

Street Address Line 2

CityState

Zip Code
How Many Client(s) Need Treatment?*
I agree to Terms, Privacy Policy, and Cancellation Policy.
I understand that Mobile IV Medics does not provide healthcare services and will book an appointment for the selected procedure(s) to be performed by a medical provider (the “Medical Provider”) licensed to perform such procedures in the State where the procedures are performed. I understand that Mobile IV Medics will share the preceding medical history with the Medical Provider who will confirm the appropriateness of the procedure(s) and will perform and/or oversee the procedure(s) in their professional medical discretion. I certify that the preceding medical, medication and personal history statements including those previously disclosed and stated are true and correct. I am aware that it is my responsibility to inform Mobile IV Medics the Medical Provider of my current medical or health conditions and to update this history, as necessary. A current medical history is essential to execute appropriate treatment procedures.*

Clear
We aren't servicing your area, yet!
Thank you for your interest in receiving services from Mobile IV Medics. We do not currently provide services in {treatmentState}. In the meantime, keep us in mind when you're traveling and stay tuned! We are continuously growing and expanding. Please sign up below to be notified as soon as we expand to your location.
I agree to Terms and Privacy Policy
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
We're Coming in May!
Thank you for your interest in receiving services from Mobile IV Medics. We do not currently provide services in {treatmentState} but we're coming very soon! Please enter your information and sign up below to be notified as soon as we expand to your location.
I agree to Terms and Privacy Policy
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I agree to Terms and Privacy Policy
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Please Enter Your Information Below

Medical Screening

Additional Medical Screening

We will try our best to take care of you as soon as possible! Our standard hours of operation are 8AM to 8PM, 7 days a week, but we may be able to help you during off hours.

Please be on the lookout for communication regarding your appointment scheduling shortly.

We aren't servicing your area, yet!

We're Coming in May!

Please Enter Your Information Below

Medical Screening

Additional Medical Screening

We will try our best to take care of you as soon as possible! Our standard hours of operation are 8AM to 8PM, 7 days a week, but we may be able to help you during off hours. Please be on the lookout for communication regarding your appointment scheduling shortly.

We aren't servicing your area, yet!

We're Coming in May!

We will try our best to take care of you as soon as possible! Our standard hours of operation are 8AM to 8PM, 7 days a week, but we may be able to help you during off hours.

Please be on the lookout for communication regarding your appointment scheduling shortly.