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Treatment Menu
What Is IV Therapy
About Us
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Home
Treatment Menu
What Is IV Therapy
About Us
Contact Us
Find Your Drip
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One last step - Medical Form
Personal Info
Full Name
*
Email
*
Phone
*
Drip Type
*
Myers Cocktail
P.V.R. (post-viral relief)
Full Tank
Glow
SOS
Immunize
Energize
Hydrate
Next
Medical Info
Please check X if you have any of the following:
*
None
Cardiovascular disease
High blood pressure
Low blood pressure
Diabetes
Congestive heart failure
COPS
Ashtma
Atrial Fibrillation
History of Cancer
Hyperthyroidism
Liver disease
Migraines
Epilepsy
Kidney disease
Arthritis
G6PD deficiency
Crohn's disease
Colitis
Surgeries or hospitalizations in the past 12 monthsֿ?
*
Select...
No
Yes
If so, detail
*
Do you have any allergies?
*
Select...
No
Yes
If so, detail
*
Routine supplements:
*
Select...
No
Yes
If so, detail
*
Vegetarian or vegan:
*
Select...
No
Yes
If so, detail
*
Pregnant:
*
Select...
No
Yes
If so, detail
*
Breastfeeding:
*
Select...
No
Yes
If so, detail
*
Alcohol consumption:
*
Select...
Never
Rarely
Moderate
Daily
Physical exercise:
*
Select...
Never
Rarely
Moderate
Over 4 times weekly
How many hours do you sleep at night:
*
Select...
Under 5 hours
Between 5-8
Between 8-10
Over 10 hours
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