Im wellnessIM wellness ($125) Ingredients GlutathioneVitamin CZincB-ComplexMagnesium Customer Information:EmailFirst NamePhone NumberAddressAddress 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 PreferencePreferred Date and Time:Additional 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