Migraine

Migraine

Migraine ($175)

Ingredients

Ketorelac
Glutathione
Vitamin C
Zinc
B-Complex
Magnesium

Customer Information:

First Name

Last Name

Phone Number

Address

Address Line 1

Address Line 2

City

State

Date Of Birth

Emergency Contact Name:

Emergency Contact Number:

Health Information:

1. Medical History

Are you currently under the care of a physician?

Yes

Please list any existing medical conditions:

Are you taking any medications?

Yes

If yes, please list medications and dosages:

2. Alergies

Do you have any allergies?

Yes

If yes, please specify the allergies:

3. Pregnancy/Breastfeeding:

Are you currently pregnant or breastfeeding?

Yes

If yes, please provide details:

IV Therapy Preferences

Preferred 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.

Migraine ($175)

Customer Information:

Health Information:

IV Therapy Preferences

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