DR.REVIVE IV Mobile Service

Driver’s License, Passport or Government issued ID. (PLEASE MAKE SURE THE PICTURE IS STRAIGHT)
Driver’s License, Passport or Government issued ID. (PLEASE MAKE SURE THE PICTURE IS STRAIGHT)

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Please select your treatments

HIS IV

Vitamins and Minerals Essential for Male

4,900.00THB Quantity

HER IV

Vitamins and Minerals Essential for Female

4,900.00THB Quantity

SUPER IMMUNITY+

Boost Your Immune System

5,900.00THB Quantity

POST-COVID

Boost your immune system and help you recover from COVID faster

5,900.00THB Quantity

MAYERS' COCKTAIL

Powerful Vitamins, Minerals, and Antioxidants

6,200.00THB Quantity

SUPERIOR (ALL-IN)

The Most Powerful Vitamins, Minerals, and Antioxidants

12,900.00THB Quantity

NAD+ / Anti-Aging

World Famous Brain Booster, Anti Aging

9,200.00THB Quantity

Rejuvenate

Maximize Your Overall Wellness from the Inside Out

5,900.00THB Quantity

SUPER GLOW X2

Radiant and Glowing Skin! Diminishes dark circles, acne, scars, and helps fade dark spots.

5,900.00THB Quantity

BEAUTY

Elevate Beauty to the Highest Level from the Inside Out Hair, skin, and nails.

4,900.00THB Quantity

ATHLETIC PERFORMANCE

Before - After sport events Boost your performance - Recover faster

5,900.00THB Quantity

HANGOVER CURE

Pre weekends / After festivals

5,900.00THB Quantity

FOOD POISONING

Restore fluids, Reset body

4,900.00THB Quantity

JET LAGGED

Long flights recovery

4,900.00THB Quantity

POST-COVID

Boost your immune system and recover faster.

6,200.00THB Quantity

DETOX-DIET

Kick start your diet

4,900.00THB Quantity

MIGRAINE

Fast pain relief

4,900.00THB Quantity

RELAX-CALM

Help you Sleep better

4,900.00THB Quantity

LIVER DETOX

For drinkers or someone who take lots of medications.

5,500.00THB Quantity

SUNBURN RECOVERY

Replenishes your body with fluids and repairs damaged skin caused by severe sunburn.

4,900.00THB Quantity

IRON (Blood Test Required / at Clinic only)

Replenishes your body with fluids and repairs damaged skin caused by severe sunburn.

11,000.00THB Quantity

HIGH DOSE VITAMIN C

Blood or urine Test Required (at Clinic only)

9,000.00THB Quantity

CHELATION

Rejuvenate your heart liver and brain. (Blood Test Required / at Clinic only)

9,000.00THB Quantity

CREATE YOUR OWN

PLEASE CALL 065-149-6622 or add us LINE @drrevivethailand

FreeTHB Quantity

B-12 Injection (800฿)

5 stars Review us on Google / Video, Photo Tag us on IG

FreeTHB Quantity

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Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Appointment*
Profile-Medical History / ประวัติทางการแพทย์
Mr. / นายMrs. / นางMiss / นางสาว
Full Name / ชื่อและนามสกุล *

First NameLast Name
Email*
example@example.com
Phone Number (Thailand)
(###) ###-####Format: (000) 000-0000.
PhoneLINEInstagram DMWhatsappFacebook Massage
ID / profile / Number
LINE / Instagram DM / Whatsapp / Facebook Massage
Please select your Hotels
Service Address (Bangkok area only)

Full Address

Hotel Name / Phone Number / Room Number / Unit Number

CityState / Province

Postal / Zip Code
Chest pain / แน่นหน้าอกRespiratory /โรคทางเดินหายใจCardiac disease / โรคหัวใจCardiovascular / โรคหัวใจและหลอดเลือดHematological / โรคทางโลหิตวิทยาLymphatic / โรคต่อมน้ำเหลืองNeurological / โรคระบบประสาทPsychiatric / โรคจิตเวชGastrointestinal / โรคระบบทางเดินอาหารGenitourinary / โรคระบบทางเดินปัสสาวะWeight gain / น้ำหนักตัวขึ้นผิดปกติWeight loss /น้ำหนักตัวลดผิดปกติMusculoskeletal / โรคกล้ามเนื้อและกระดูกNone / ไม่มี
Asthma / โรคหอบหืดCancer / โรคมะเร็งCardiac disease / โรคหัวใจDiabetes / โรคเบาหวานHypertension / โรคความดันโลหิตสูงPsychiatric disorder / โรคทางจิตเวชEpilepsy / โรคลมบ้าหมูNone / ไม่มี
No / ไม่Yes / ใช่
IF YES, PLEASE LIST BELOW / ถ้าใช่ โปรดระบุรายการด้านล่าง
No / ไม่Yes / ใช่
IF YES, PLEASE LIST BELOW / ถ้าใช่ โปรดระบุรายการด้านล่าง
Yes / ได้Yes without my face / ได้โดยไม่มีใบหน้าของฉันNO / ได้ไม่
Instagram / Yes Tag me on Instagram (please provide your profile name) @ ได้แท็กฉันบน Instagram
Ex: @doctorrevive
I voluntarily give my consent to physicians, nurses, medical personnel and/ or other staffs in the team of the Hospital to investigate,treat or perform other practices in accordance with professional principles for my benefit of investigation and treatments for my illness. I have adequately been informed and well understood about health information related to the investigation and treatments aswell Declaration of Patient’s Right, including receiving a copy of Patient’s Rights and Patient’s Responsibilities I consent to the medical facility collecting, using, and processing personal data to analyze my health condition. and contact to communicate Send medical news and offer promotions for products and services .*

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Time

Hour Minutes

AM/PM Option
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B/W
HIGHT
HR
BP
TEMP
VITAMIN CB-6B-12B-COMPLEXCALCIUMZINCGLUTATHIONENAD+LYSINETAURINEBIOTINTORADOLDECADRONRANITIDINEMAGNESIUMBENADRYLOther
NOTES*
TREATMENT SITE
TREATMENT SITE
TREATMENT SITE
TREATMENT SITE
SOCIAL MEDIA
SOCIAL MEDIA
SOCIAL MEDIA
SOCIAL MEDIA
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Profile-Medical History / ประวัติทางการแพทย์

FOR OUR NURSES