Name
*
First Name
Last Name
Mailing address
*
Full street address and town.
Phone
*
(###)
###
####
Email
*
If you would like us to come to you, what is the address where we should come to provide our services?
Full street address, and town. Please include any extra details that will help us locate you.
Emergency Contact Person and Relationship
Emergency Contact Phone Number
(###)
###
####
Date of Birth
MM
DD
YYYY
Age
*
What is your current weight?
*
Has your weight changed significantly in the last year?
*
How tall are you?
*
Why are you making an appointment with us?
In your own words, tell us why you are interested in receiving our services
Which IV are you interested in?
*
Select all that apply
If you would like more than one High Dose Vitamin C IV infusion, how often would like to receive infusions?
*
How did you hear about us?
*
Are you pursuing this treatment because of a cancer diagnosis? If yes, what type and stage of cancer have you been diagnosed with?
*
If you have a cancer diagnosis, are you currently receiving chemotherapy, or have you received chemotherapy in the past? If yes, please describe.
*
What surgeries have you had in the past?
*
Do you have any other existing health issues?
*
We need a full picture of your current health. Please describe any health issues you are currently dealing with.
What medications, drugs, and supplements are you currently taking?
*
Anything that you are regularly or semi-regularly taking, including prescription, over-the-counter, recreational, vitamins, and other supplements. It is important that you disclose everything so we can provide you with the best treatment possible.
Have you had any of the following bloodwork done within the last 12 months?
*
