First Name
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Last Name
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Cell Phone Number
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Email Address
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Address
Treatement Address
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Preferred Date
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Do you know which IV you would like?: Please note that the IV you choose is completely customizable and add ins can be given at the time of your appointment.
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The Starter
Bronze
Silver
Gold
Myers Cocktail
The Ultimate Myers
The Immune Booster
The Migraine Kicker
The Hangover Blaster
The Performance Flex
The Kitchen Sink
Metabolism Boost
Fountain of Youth
Pre/Post Surgical
I would like to discuss with my provider to determine which IV infusion is best for me.
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What is the reason you are seeking IV services? If applicable, could you share any symptoms or concerns?
Please select if you have ever been diagnosed or told you have:
Congestive Heart Failure
Kidney/Renal Failure, or on Dialysis
Blood Clotting Disorder or Hemophilia
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