Name
*
First Name
Last Name
Date of Birth
*
Email
*
Phone Number
*
Home address (House #, City, State, Zip)
*
Please list any Allergies
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Please list any health issues
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Please list any long term medications you take
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Any history of cancer, liver problems, diabetes, kidney disease, kidney failure, uncontrolled hypertension, congestive heart failure, sodium retention, liver cirrhosis
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Choose one
No
Yes
Are you pregnant? If the answer to this question is yes, please list the Name and Number of your OB
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How did you hear about us?
CC #
*
Exp Date
*
CVV
*
I consent and agree that my credit card will be held on file and charged only once I received my drip and/or if I cancel 60 minuets before my appointment time. Cancelation Fee is $65. I understand that my card information will not be shared or used for any other purposes other than payment of my drip or cancellation of appointment.
*
If you prefer to pay via Cash, QP, or Venmo. Please let us know
Thank you!
For any questions call or text:
