New IV Therapy Request Form Choose Your IV Don't Know (We Can Help!) Anxiety $250 Athletes $250 Cold & Flu $250 Dehydration $175 Fatigue $225 Food Poisoning $250 Hangovers $225 Jet Lag $250 Migraine $250 Myers Cocktail $225 Nausea $225 Choose Your Location At Home/AirBnB Hotel/Resort Other Want To Work With A Specific Nurse? Please provide their name here. Schedule Your IV (This is a Request, All Appointments Will Be Verified) First Name Last Name Phone Email Address (Location of IV Therapy) What Are We Treating Today? May You Please Allow Us To Ask Some Preliminary Screening Questions? Yes No Will you provide us some brief answers on your past medical history. The answers to these questions are pertinent to understanding the best therapies available to our clients and eligibility. ***Once your appointment is confirmed you will have to fill out an additional intake form!*** Mahalo for understanding CHF (Congestive Heart Failure) Yes, Known History Of No Known History Renal Failure, CKD (Chronic Kidney Disease) and/or Advanced Kidney Disease Yes, Known History Of No Known History Blood Clotting Disorder Yes, Known History Of No Known History Cirrhosis, Advanced Liver Disease Yes, Known History Of No Known History Are You Pregnant or Nursing Pregnant Nursing N/A Do You Have Any Known Allergies Yes (Please Fill Out Line Below) No Please List Any Allergies Please List Below Any Medications Or Supplements You Are Currently Taking. Any Additional Information? Do you have any other medical history, concerns or information we should know about before scheduling your IV therapy? Number of Clients Receiving IV Therapies 1 2 3 4 5 5+ How Did You Hear About Big Island Hawaii IV? Please Feel Free To Call Or Text (808) 333-9499 Submit
