Kindly Fill the form below to request an appointment for our Intravenous Therapy sessions. 25% Membership formMembership PackageCustomer Information:First NameLast NamePhone NumberEmailAddressAddress Line 1Address Line 2CityStateDate Of BirthEmergency Contact Name: Emergency Contact Number:Health Information:1. Medical HistoryAre you currently under the care of a physician? Yes NoPlease list any existing medical conditions:Are you taking any medications? Yes NoIf yes, please list medications and dosages:2. AlergiesDo you have any allergies? Yes NoIf yes, please specify the allergies:3. Pregnancy/Breastfeeding:Are you currently pregnant or breastfeeding? Yes NoIf yes, please provide details:IV Therapy PreferencesSelect IV Therapy Package: (Choose any 6) Glow With Me ($150) Pick Me Up ($175) Anti-Fatigue ($175) Rejuvenate ($199) Hangover ($199) Migraine ($175) Pregnancy ($175) IM Wellness ($125) Performance Plus ($199) Skinny shot Lipo B shots ($35) Skinny shot Lipo B shots Bulk of 5 ($140)Preferred Date and Time:Location: In-Clinic Session Home/Office VisitAdditional Requests or Preferences I have provided accurate information about my health and medical history. I understand that IV therapy involves the administration of fluids and nutrients through an intravenous line. I consent to the procedure and acknowledge that the results may vary from person to person.Request Session