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Home
About
About Us
Our Team
Appointments
Our Services
Pricing Plans
Enquiry form
Blog
Contact
Home
About
About Us
Our Team
Appointments
Our Services
Pricing Plans
Enquiry form
Blog
Contact
Home
Enquiry form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Phone Number
*
Email
*
Gender
Male
Female
Non-Binary
Other
Medical Conditions:
List any current or past medical conditions (e.g., heart disease, diabetes, etc.).
Primary Care Physician
Reason for IV Therapy
Current Medications
List all medications, including dosage and frequency.
Allergies
Specify any known allergies, including medications, foods, or other substances.
Previous Surgeries:
Provide details on any surgeries the patient has undergone.
Requested IV Therapy:
Specify the type of IV therapy requested (e.g., hydration, vitamin infusion, etc.).
Frequency of IV Therapy:
Indicate how often you plan to receive IV therapy sessions.
Consent for Treatment:
give your consent for treatment
Pregnant or Breastfeeding?
Pregnant
Breastfeeding
Non-applicable
Questions for us?
Submit
hello@88ivtherapy.com
|
+02081455603
|
London, England
A:
Seestrasse 21, Zurich, Swisse
E:
wellmont@qodeinteractive.com
T:
00 123 456 789
;
00 123 456 788