High-dose Vitamin C IV Therapy

Medical History

Do you have any existing medical conditions?

Yes
No

e.g., diabetes, hypertension, heart disease, etc.

Please specify

Are you currently taking any medications?

Yes
No

Please list them

Do you have any allergies, especially to medications or vitamins?

Yes
No

Please specify

Have you ever received IV therapy before?

Yes
No

Please describe your experience

Specific Interest in High-Dose Vitamin C IV Therapy

Why are you interested in High-Dose Vitamin C IV Therapy?

Select all that apply

Please specify

Have you been diagnosed with cancer or any other serious illness?

Yes
No

Have you discussed High-Dose Vitamin C IV Therapy with your healthcare provider?

Yes
No

What was their recommendation?

How would you describe your overall lifestyle?

Very active
Moderately active
Sedentary

How often do you exercise?

Daily
A few times a week
Rarely
Never

How would you rate your current diet?

Very healthy
Moderately healthy
Unhealthy

Do you consume alcohol?

Yes
No

How often?

Daily
Weekly
Occasionally

Do you smoke?

Yes
No

How many cigarettes per day?

Expectations and Goals

What specific benefits do you hope to achieve with High-Dose Vitamin C IV Therapy?

Are there any concerns or questions you have about High-Dose Vitamin C IV Therapy?

Is there any other information you would like to provide that you think might be relevant?

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

How much do you budget for your wellness each year?

Less than $1000
Less than $10,000
More than $10,000

We know this question may feel personal—but it's important. It helps us prioritize patients who are committed to long-term results, and tailor recommendations that make sense financially and medically.

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

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We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

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Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations