• Step 1 of 3 - Information

  • Please Enter Your Information

  • Format: (000) 000-0000.
  • Who will be receiving treatment from MIVM?*

  • The information entered on this form must reflect the person that is going to be receieving treatment by Mobile IV Medics 

    Please verify the client's information (person receiving treatment) is entered above and that persons information is entered subsequently for the resepective questions on this form

  • Is the person to be receiving treatment's information entered in fields above (Name, Email, Phone)?*

  • You have indicated that the information entered on this form is someone other than the person to be receiving treatment. The information entered on this form must be for the client. Please update the Name, Email, and Phone Number above to reflect the client's information

    Failure to do so will result in delays and/or denial for treatment

  • Travel Fee Required

  • Your Location - {azPhysical}, {azFull287} {ZC}

     

    Thanks for your interest in services provided by Mobile IV Medics. Unfortunately, we do not currently provide services at your location ({azPhysical}, {azFull287} {ZC}). We may be able to help with the addition of a travel fee. Please indicate your acceptance of the required travel fee below before proceeding with your request. 

     

    Due to resource allocation constraints, acceptance of the travel fee does not garauntee your request with be able to be be staffed, though we will try our best!

     

    If you believe you have reached this page in error, please press the back button on the bottom left of your screen and correct your Zip Code on the first page of this form. If you still need assistance, please give us a call or text at (833) 483-7477.

  • I accept the addition of a $40 travel fee to be added to my appointment*

  • Step 2 of 3 - Service

  • Medical Screening

    Enter/Use Client's Information
  •  - -
  •  - -
  • Is the person to be receiving treatment able to consent to treatment and make their own medical decisions?*

  • You have selected that the client is unable to consent to treatment. All clients consulted on and treated by MIVM must be able to consent to receiving treatment themselves

    Exceptions may be considered with an infusion treatment order from the clients primary care or other managing medical provider. Additional details regarding necessary next steps will be provided following your submission of this form

  • Please select ALL of the following that apply to the client:*

  • Step 2 of 3 - Service

  • Additional Medical Screening

  • Have you had your ejection fraction (EF) measured within the last 6 months?*
  • Do you have documentation of your most recent ejection fraction (EF) result?*
  • Have you provided documentation of your most recent ejection fraction (EF) documentation to MIVM?*
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  • Have you had your kidney (renal) function measured within the last 6 months?*
  • Do you have documentation of your estimated glomerular filtration rate (eGFR)?*
  • Have you provided documentation of your most recent estimated glomerular filtration rate (eGFR) documentation to MIVM?*
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  • Pulmonary arterial hypertension PAH is a rare disease specifically affecting the pulmonary arteries. This is NOT the same as general hypertension (HTN) or heart/coronary artery disease (CAD).

  • Please confirm that you have been diagnosed with pulmonary arterial hypertension (PAH)*
  • Do you take any medication for your fluid retention?*
  • Do you have a history of heart, liver, or kidney problems?*
  • Do you urinate normally?*
  • Are you on any fluid restrictions?*
  • Is your primary care physician or other managing physician aware of your fluid retention?*
  • Do you have fluid build up currently?*

  • Step 3 of 3 - Submit

  • When would you like to request your appointment?*

  • We will try our best to take care of you as soon as possible! Our standard hours of operation are 8AM to 8PM, 7 days a week, but we may be able to help you during off hours.

    Please be on the lookout for communication regarding your appointment scheduling shortly.

  •  - -

  • By subscribing, you agree to receive recurring automated marketing and personalized text messages from Mobile IV Medics at the phone number you provide. Consent is not required to make a purchase. Reply HELP for assistance or STOP to opt out at any time. Message frequency may vary. Standard message and data rates may apply. 

  • We aren't servicing your area, yet!

  • Your Location - {azPhysical}, {azFull287} {ZC}

    Thanks for your interest in services provided by Mobile IV Medics. Unfortunately, we do not currently provide services at your location ({azPhysical}, {azFull287} {ZC}).

     

    In the meantime, keep us in mind when you're traveling and stay tuned! We are continuously growing and expanding. Please sign up below to be notified as soon as we expand to your location.

     

    If you believe you have reached this page in error, please press the back button on the bottom left of your screen and correct your Zip Code on the first page of this form. If you still need assistance, please give us a call or text at (833) 483-7477.

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