IV Vitamin Infusion – Park Avenue

Name(Required)

First Last

Date of Birth(Required)

Mobile Number(Required)

Street Address(Required)

Street Address City State ZIP Code

Preferred Contact

Email(Required)

(By providing my email, I agree to receiving clinic email reminders, health updates, promotions, etc)

Age

Cell

Sex(Required)

In case of emergency, whom should we contact

How did you find out about our services?

Have you received IV Therapy before? What was your experience like?(Required)

Reason for infusion?(Required)

When would you like to schedule the infusion?(Required)

(answer every question as all are important)

Are you experiencing any of the following?

Please list all allergies (known and suspected):

Please list all current and past medical conditions, diagnosis, hospitalizations, surgeries

Please list all prescription drugs and supplements you are currently taking and doses

Date of last Physical Exam/Blood Test (optional)

Please check if you have any of the diagnoses below:

Additional notes

Product Name

Drips Order(Required)

Hangover Drip

Prenatal Drip

Wellness Drip

Energy Boost Drip

Immune Boost Drip

Cold / Flu Relief Drip

Dehydration Drip

Premium Multi-Vitamin Drip

Hydration Fluids

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name