IV / Injection Intake Form
NAD+, IV Vitamins, Vitamin Injections
Which service are you most interested in booking?
Please Select
NAD+ self injection
NAD+ with Glutathione self injection
Vitamin self injection
IV Therapy at home
Patient Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
What is your general purpose of treatment?
*
General Health & Wellness
Acute Illness
Adjuvant treatment of a chronic condition
Other
Any history of conditions with your heart, kidneys or liver?
*
Please Select
Yes
No
If yes to the above questions, please explain.
Have you received IV Therapy (outside of a hospital setting) before?
*
Yes
No
What was your experience like?
Please check if you have any of the diagnoses below:
*
High Blood Pressure
Arrhythmia
Abnormal EKG
CHF
Low Blood Pressure
Angina
MI / Heart Attack
Diabetes
Bleeding Disorder
Ankle Swelling
Kidney Disease
Asthma
G6PD Deficiency
Anxiety
Congestive Heart Failure
Edema
Sudden Weight Loss
Cancer
None of these
Other
Please list any known allergies (if none, write "none")
*
Please list all current and past medical conditions, diagnosis, hospitalizations, surgeries (if none, write "none")
*
Please provide a list of all the prescription drugs and supplements you are presently taking, including their respective doses. (if none, write "none")
*
How did you hear about us?
Anything additional you would like us to know? Preferred appointment times, or something else?
Submit
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