We have disabled our online booking form. Please copy and paste the intake form below into a text message, fill in your answers, and send it to 480-352-2170

INTAKE FORM

Name:
Phone Number:
Email:

Date/Time IV desired: 

(We will do our best to be there at the date/time you request, but please be flexible if possible. You will receive a text/call to confirm the date/time) 

Address where you will be receiving the IV:

Which IV blend would you like? (Put an X by the blend you want)
- Myers Cocktail ($199)
- immune Blend ($179)
- Energy+Performance ($165)
- Hangover Cure ($149)
- Hydration ($125)

Which Add-ons would you like? (Put an X be the add-ons you want)
- Vitamin B12 ($30)
- Vitamin C ($45)
- Glutathione ($60)
- Zofran/Nausea Relief ($60)
- Toradol/Pain Relief ($40)
- Extra 1L Fluids ($30)

Are you pregnant/breastfeeding?

Do you have high blood pressure/Hypertension?

Do you have any heart rhythm conditions or have you been told you have a "long QT"?

Do you have active liver or kidney disease?

Have you ever had any complications for IV Placement (are you a "hard stick", do your veins blow easily, etc..)?

Please list any allergies:

Please list any prescribed medications:

Do you have ANY other medical conditions? (Please list)