IV Therapy Scheduling Form

IV Therapy Scheduling Form

Drip, Drip, Hooray! Your Wellness Journey Starts Here! We’re thrilled you’ve chosen East Coast IV for your IV therapy services—Maryland’s premier provider of revitalizing, feel-good infusions! Use the form below to lock in your appointment and get ready to fell better from the inside out!

For the most up to date pricing, please visit www.EastCoastIV.com

Patient Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

By checking the "Yes" box, you agree to receive promotional and marketing messages, notifications, and customer service communications from East Coast IV. Message and data rates may apply. Consent is not a condition of purchase. Message frequency varies.*

YesNo

Email*

example@example.com (appointment confirmations will be sent here)

Home or Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Date of Birth *

Date

Is this the patients first time scheduling IV therapy with East Coast IV?*

YesNo

Are you scheduling IV therapy for a group?*

No, I am scheduling IV therapy for one personYes, This will be group of 2 or more!

How many people will be receiving IV therapy? (Including yourself) *

Client Name*

First NameLast Name

Client Name*

First NameLast Name

Client Name*

First NameLast Name

Client Name*

First NameLast Name

If this is the first time your crew is getting IV therapy with East Coast IV, please copy and paste this link and shoot it over to the newbies:

https://form.jotform.com/241582955400153

Have them fill out their health history forms and waivers ahead of time—it’s like RSVPing to the hydration station! This quick step makes everything run smoother and faster when our providers roll up, ready to bring the good vibes (and IVs). They can tap it out right from their phone—just send it via text and let them join the prep party!

Thanks for helping us keep things flowing!

What is your reason for choosing IV therapy today?*

Sick Visit (Flu, COVID, Stomach bug, food poisoning, dehydration, migraine, etc.)Hangover/Pre-planning for party or event (Bachelorette, Bachelor, Holiday, etc.)General Health and WellnessImmunity BoostNAD+ IV TherapyOther

Which IV therapy would you like to have?*

Where would you like to receive your IV therapy?*

I will come to one of your officesI would like you to come to me

I understand that East Coast IV’s service area covers Harford, Baltimore, Cecil, and Howard Counties, as well as Ocean City and Baltimore City.*

Yes

Please select which office you would like to receive IV therapy at:*

Belcamp, Maryland - 1200 Brass Mill Rd. Suite BOcean City, Maryland- 103 120th St, Suite KColumbia, Maryland - Journey Within Wellness Center

Is your home or mailing address the location we are sending a provider?*

YesNo

Which address would you like to receive your IV therapy at? *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list any specific instructions to access this property. (Parking instructions, Hotel Name/unit numbers, gate/door codes, etc)

Pick a date and time that suits you best! We’ll do everything we can to accommodate your request, though availability depends on our current schedule.*

Date

Hours of operation are from 9am until 5pm, 7 days a week.

AM/PM Option

Gender assigned at birth*

MaleFemale

Current Weight (lbs)*

Current Height*

Do you take any prescription or over-the-counter medications?*

NoYes

Please list any medications that you are currently taking*

Allergies to medication*

No known allergiesYes (Please List)

Please list any medical conditions that you have:*

Consent and Acknowledgment for East Coast IV, LLC Services

I consent to the insertion of a peripheral intravenous catheter (IV) and the infusion of fluids, vitamins, minerals, and/or medications under the direction of Jessica Abernathy, CRNP, and trained non-physician staff skilled in safe IV insertion, monitoring, stabilization, and removal.

I understand that no guarantees have been made regarding the results, effectiveness, or duration of effects, as responses vary by individual. I acknowledge that statements about natural supplements (e.g., vitamins, amino acids) have not been evaluated by the FDA and are not intended to diagnose, treat, cure, or prevent any disease. If safety concerns arise, the procedure or infusion may be discontinued.

Risks and Responsibilities

I am aware of the risks of peripheral IV catheterization and infusion, including but not limited to irritation, bruising, pain, infection, phlebitis, venous thrombosis, shortness of breath, allergic reactions, fluid overload, medication interactions, and death. Despite these risks, I consent to the procedure and may withdraw consent at any time. I confirm that my provided medical history is accurate, understanding that misleading information could result in serious harm or death. I also affirm I am not under the influence of recreational drugs or alcohol during treatment and accept responsibility for any consequences of providing false information in this regard.

Payment and Fees

East Coast IV, LLC does not participate in health insurance plans. I may use an HSA or flex spending account for payment. If insurance denies coverage, the credit card on file will be charged, and I am responsible for all non-refundable treatment costs, regardless of outcomes. For mobile infusions, a $40 travel fee applies if only one infusion is administered at my location. A $50 non-refundable cancellation fee will be charged to the credit card on file for no-shows, cancellations with less than 24 hours notice and if you are more than 30 minutes late to your appointment.

Communication

I consent to East Coast IV contacting me via phone, SMS or email for time sensitive information regarding my upcoming appointment and follow ups if necessary.

Authorization for Use of Patient Information and/or Photographs/Video

At East Coast IV, LLC, we are dedicated to advancing healthcare through education, training, and community engagement. We deeply value the support of our patients who choose to share their experiences to help us fulfill this mission. Your privacy and the confidentiality of your medical information are our top priorities, and we will only use your information or images with your explicit permission. By acknowledging this form, you authorize East Coast IV, LLC and its affiliates to use your name, health-related information, photographs, videos, or interviews for purposes such as medical training, education, public relations, communications, or promotional activities. This may include publications, educational materials, social media, or other promotional content.

Important Information

Please note that once information, photographs, or videos are shared, East Coast IV, LLC cannot control how they may be used or shared by third parties. This authorization remains valid from the date of your signature until you withdraw it in writing. If you choose to withdraw your consent, we will discontinue using your information or images, but we cannot retract any disclosures made prior to your withdrawal. East Coast IV, LLC is not responsible for third-party use of previously disclosed materials. To withdraw your authorization, please send a written request to: East Coast IV, LLC 1200 Brass Mill Road, Suite B, Belcamp, MD 21017

HIPPA Statement

This HIPAA Privacy Notice applies to “Protected Health Information” or “PHI”. PHI is a subset of the personal information that we may collect from you when we submit a claim to your insurance provider so that they can reimburse us for the products or services that you are purchasing. Because PHI is regulated by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), we are required to provide you with this notice. This HIPAA Privacy Notice only covers your PHI and is incorporated as a portion of our complete Privacy Policy. In the event that there are any conflicts between our HIPAA Privacy Notice and our Privacy Policy, the terms of the HIPAA Privacy Notice will take priority if the subject is your PHI, and the Privacy Policy will control if the subject is any non-PHI information that we may collect from you. East Coast IV, LLC may use and disclose your PHI for many different reasons. PHI includes information that can be used to identify you that we have created or received about your past, present, or future health condition, such as a prescription. We must provide you with this notice about our privacy practices regarding use and disclosure of your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. Below, we describe the different categories of uses and disclosure. Our Uses and Disclosures of your PHI:
• Help manage the health care treatment you receive
• Run our organization
• Pay for your health services
• Administer your health plan
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests and work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to
the public good, such as public health and research. We have to meet many conditions in the law before
we can share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Your Rights:
HIPAA gives you certain rights related to your PHI. You may exercise any of these rights at any time by contacting us at info@EastCoastIV.com:
• Get a copy of your health and claims records
• Correct your health and claims records

• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices:
For certain health information, you can tell us your choices about what we share. If you have a clear
preference for how we share your information in the situations described below, talk to us. Tell us whatyou want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in payment for your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when
needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice:
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, on our web site, and we will mail a copy to you.

Certification

By signing below, I confirm I have read and understood this document.

Type a question*

How did you hear about East Coast IV?*

Who referred you? (First and Last name) This is for their $25 credit!

Coupon Code

Discount will be applied at time of sale

Medical History and Waiver