Lifespan Health IV Therapy Request Form InstagramThis field is for validation purposes and should be left unchanged.Thank you for your interest in Lifespan Health's IV therapies. Please complete and send this brief health history.ABOUT YOUYour Name(Required) First Last Your Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code CONTACT INFORMATIONHow can we reach you?Your Email Address Your PhonePreferred Method of ContactEmailPhoneNo PreferenceSTANDARD IV THERAPIESAppropriate for everyoneWhich IV(s) would you like to schedule? Myers Cocktail Myers Plus Cocktail Glutathione NAD+ Nicotinamide riboside (NR) Amino Acid Blend Which injection(s) would you like to schedule? Vitamin B12 Glutathione NAD+ Vitamin D3 ADVANCED IV THERAPIESThese IVs can be scheduled after brief consultation with a Lifespan Health provider, to be sure the therapy meets your needs. Which advanced IVs would you like to consider? Vitamin C, high-dose Methylene Blue Alpha Lipoic Acid Phosphatidylcholine Chelation: CaEDTA, DMPS, DTPA Cardiovascular EDTA Acute Illness Protocol Brain Restore Protocol PK Protocol Addiction Protocol PowerPUSH BRIEF MEDICAL HISTORYPlease provide a few details about your healthHEALTH CONDITIONS Health Conditions / Diagnoses Add Remove If you have NO known health condtions, type noneCURRENT MEDICATIONSMedication NameDose (mg, ml, iu, etc.)FrequencyReason for taking Add RemoveIf you take NO medications, type: NoneMEDICATION ALLERGIESMedication nameDescription of reaction (if known) Add RemoveIf you have NO medication allergies, type: NoneFEMALES: Are you pregnant Yes No Are you breastfeeding? Yes No QUESTIONS?Please let us know if you have questions
