Submit Your Appointment Request Today
Thank you for choosing East Coast IV, Maryland's premier health and wellness provider! Please use the following form to request your appointment and a scheduling coordinator will confirm your appointment shortly. If you have any other questions about scheduling, you can call or text (443) 252-8005.
Patients Name
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First Name
Last Name
Email
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Phone Number
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Date of birth
*
-
Month
-
Day
Year
Date
Please select a treatment:
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Please Select
IV Therapy
Medically Managed Weight Loss (Semaglutide/Tirzepatide injections)
TRT - Testosterone Replacement Therapy
BHRT - Biote Pellet (Male for Female)
Vitamin Injections (B-12, Lipo-B, Vitamin D)
Are You A New Client?
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Yes
No
Where would you like to receive your IV therapy?
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Please Select
Mobile
In office
Which office would you like to receive your IV therapy?
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Please Select
Belcamp
Ocean City
Columbia
Which office would you like to receive your vitamin injection?
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Please Select
Belcamp
Ocean City
Columbia
Which office would you like to receive your Semaglutide injection?
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Please Select
Belcamp
Ocean City
Columbia
Ship to me
Which county/city would you like to receive your IV therapy?
*
Please Select
Harford County
Baltimore County/City
Cecil County
Howard County
Ocean City/Worcester County
If you do not reside in our travel area, please call before attempting to schedule.
Please choose your IV therapy:
*
Please Select
The White Marlin Open Bag ($180.00)
Super Immune Stimulus ($225.00)
Hangover Miracle ($165.00)
Myers Cocktail ($170.00)
High Energy Booster ($195.00)
Migraine Relief ($165.00)
Beauty Treatment ($185.00)
Performance and Recovery Booster ($175.00)
Custom IV therapy (Price varies based on additions)
NAD+ Infusion (Price varies based on dosage)
Unsure
Please select the Injection you would like to receive
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B-12
Lipo-B
Vitamin D
Biotin
Which low T symptoms are you experiencing?
Low Sex Drive
Muscle Loss
Weight Gain
Reduced Erectile function
Fatigue
Loss of Muscle Tone
Depression
If mobile, please provide service address:
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Street Address
Apt, Condo or Room Number (If applicable)
City
State
Zip Code
I acknowledge that opting for an East Coast IV healthcare provider to attend to my location entails a $40 travel fee if only one person is receiving IV therapy services. Additionally, I am thoroughly acquainted with East Coast IV LLC's operational hours and the potential unavailability of same-day appointments. It is advisable to proactively contact East Coast IV to confirm availability, particularly as the closing time approaches, before submitting a request for same-day services
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Yes
East Coast IV Services Deposit
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East Coast IV Services Deposit
Please note that the deposit you make towards IV therapy, TRT, or MMMC services will be applied to the total cost of the treatment, effectively reducing the final amount you will need to pay upon completion of the services.
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card
I have read and understand the cancellation policy set forth by East Coast IV LLC. "For ALL appointments we require a 24-hour notice for cancellations, unless the appointment was made same day, then we require a minimum of 2 hours prior notice to cancel your appointment without being assessed a cancellation fee. Appointments that are cancel without appropriate notice, and no shows will be subjected to a non-refundable $50.00 cancellation fee. Cancelation fees will be charged to the credit card on file. In the event of a true emergency, and at the discretion of management, the $50.00 cancellation fee can be applied as a deposit towards future services rendered within ten (10) days. We Value and respect our clients & practitioners' time and appreciate your understanding."
*
Yes
How did you hear about East Coast IV?
Please Select
Google
Facebook
Family or Friend
Referral from healthcare provider
Other
Are you experiencing symptoms of COVID 19 or flu like symptoms?
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Yes
No
Please include desired date/time and any additional pertinent information.
*
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