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IV Therapy
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Semaglutide
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Ear Lobe Hole Repair
Medical Microdermabrasion
The V.I. Peel
Skin Care
Prescription Skin Products
Glycolic Facials
Medical Grade Sun Protection
Latisse
Our Programs
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Weight Loss Program Pricing
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Digital Cookbook
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Home
About Us
Contact
Providers and Staff
Blog
Refer a Friend
Site Terms
Make an Appointment
IV Therapy
IV Therapy Offering and Pricing
IV Therapy Form
Semaglutide
Cosmetic Procedures
Botox Cosmetic®
Dermal Fillers
Ear Lobe Hole Repair
Medical Microdermabrasion
The V.I. Peel
Skin Care
Prescription Skin Products
Glycolic Facials
Medical Grade Sun Protection
Latisse
Our Programs
Svelte Weight Loss Program
Weight Loss Program Pricing
FAQ’s
Digital Cookbook
Testosterone/Hormone Therapy
BioTE® Orlando
BioTE Pricing
BioTE® Testimonials
Biote-Men-Quiz
Biote-Women-Quiz
Testimonials
Menu
Home
About Us
Contact
Providers and Staff
Blog
Refer a Friend
Site Terms
Make an Appointment
IV Therapy
IV Therapy Offering and Pricing
IV Therapy Form
Semaglutide
Cosmetic Procedures
Botox Cosmetic®
Dermal Fillers
Ear Lobe Hole Repair
Medical Microdermabrasion
The V.I. Peel
Skin Care
Prescription Skin Products
Glycolic Facials
Medical Grade Sun Protection
Latisse
Our Programs
Svelte Weight Loss Program
Weight Loss Program Pricing
FAQ’s
Digital Cookbook
Testosterone/Hormone Therapy
BioTE® Orlando
BioTE Pricing
BioTE® Testimonials
Biote-Men-Quiz
Biote-Women-Quiz
Testimonials
IV Hydration Medical History Form
Date
Name
Phone
Email
Date of Birth
Allergies
Current Medications
1. Have you ever had prior IV nutrient infusion?
No
Yes
If so, when
Did you have problems with prior infusions including reactions, allergies, or access issues?
2. Do you have any of the following conditions?
None
End Stage Renal Disease
Cerebral Hemorrhage
Hyperparathyroidism
Congestive Heart Failure (CHF)
Myasthenia Gravis
Hypermagnesium
Kidney/Renal Disease
Hemolytic Anemia
Current UTI
Cardiac Arrhythmia
Low Blood Pressure
Kidney Stones
Liver disease
3. Have you been told that you need to start dialysis or are you currently on dialysis?
Yes
No
4. Are you taking or have you been told you need to take Digoxin?
Yes
No
5. Have you been told you have a decreased GFR or kidney problem?
Yes
No
Send
Call Now!
(407) 804-5200
Call Now!
(407) 804-5200
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