Master Schedule Appointment Form

Patients Name*

First NameLast Name

Email*

Phone Number*

Date of birth*

Date

Please select a treatment: *

Are You A New Client?*

YesNo

Where would you like to receive your IV therapy?*

Which office would you like to receive your IV therapy?*

Which office would you like to receive your vitamin injection?*

Which office would you like to receive your Semaglutide injection?*

Which county/city would you like to receive your IV therapy?*

If you do not reside in our travel area, please call before attempting to schedule.

Please choose your IV therapy: *

Please select the Injection you would like to receive*

B-12Lipo-BVitamin DBiotin

Which low T symptoms are you experiencing?

If mobile, please provide service address:*

Street Address

Apt, Condo or Room Number (If applicable)

CityState

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*

Yes

East Coast IV Services Deposit *

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

Total

$0.00

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?

Are you experiencing symptoms of COVID 19 or flu like symptoms?*

YesNo

Please include desired date/time and any additional pertinent information.*

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Credit Card