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Menu
Home
About Us
Contact
Providers and Staff
Testimonials
Digital Cookbook
Blog
FAQ’s
Refer a Friend
Site Terms
Weight Loss
SvelteMD Classic Weight Loss Program
Our Program
Weight Loss Program Pricing
The Use of Appetite Suppressants
Semaglutide in Office
Semaglutide Injections / Results
Pricing Semaglutide In-Office
Candidate for Semaglutide?
Semaglutide Telehealth
Our Telehealth Process
Pricing Semaglutide Injections Telehealth
Candidate for Semaglutide?
Cosmetic Procedures
Botox Cosmetic®
Juvederm Fillers
Ear Lobe Hole Repair
Skin Procedures
Glycolic Facials
Medical Microdermabrasion
The V.I. Peel
Medical Grade Skincare
Medical Grade Sun Protection
Latisse
Testosterone/Hormone Therapy
BioTE® Orlando
Pellet Pricing
Biote-Men-Quiz
Biote-Women-Quiz
IV Therapy
IV Therapy Offering and Pricing
IV Therapy Form
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
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(407) 804-5200
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