LUXE Mobile IV Service Appointment Request
Let us bring wellness to YOU!
Full Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Contact Number
Please enter a valid mobile phone number.
Email Address
example@example.com
Service Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location type (IE: Home/Office/Hotel) - Special Instructions? Nurse Preference?
Any special instructions? Gate code? Nurse preference?
Allergies
List all allergies
List all medications here:
Daily home medications
What type of IV Infusion would you like today?
Allergy Relief
Hangover Relief
Immune Support
Myer’s Cocktail
Migraine Relief
Beauty/Glow
Athletic Recovery
IV Therapy (other)
Group IV Party
Add ons requested:
Vitamin B12
Migraine Relief
Nausea Relief
Vitamin C
Glutathione
Lipo B
Lipo C
CBD IV
Vitamin D3 (IM ONLY)
NAD+
Zofran
How many clients will be receiving IVs?
Please Select
1
2
3
4
5
6 or more
Concierge fee may apply for party less than 4
Date Requested
Please Select
TODAY
In the next 24 hours
OTHER
Payment method
Please Select
Cash
Credit Card
HSA/FSA
Apple Pay
Venmo
Cherry Credit
By signing below, I consent to Luxe Mobile IV Service contacting me to confirm appointment details. I understand my appointment is subject to nurse availability and travel fees may apply.
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