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Elective IV Infusion & Injections Intake Form

Select an option
What options best describe why you are her today?
Are you a Diabetic?
Do you take vitamins?
Do you smoke?
Do you consum alcohol?
Do you use recreational drugs?
Have you ever had IV or injectable vitamin therapy?
Have you had prolonged/ regular use of NSAIDs (Advil, Aleve, Motrin, Aspirin)?
Do you take or have you taken in the last 6 months any type of blood thinner?
Do you have any of the following?
In the last 12 hours have you
Choose your Infusion

I understand that this IV infusion/IM injection is elective. I understand that there are risks associated with IV infusion and or IM injection including risk for infection, pain, redness and swelling at injection or infusion site, risk for allergic reaction, thrombophlebitis, risk of contaminated fluids and or medications, and death associated with elective IV/IM infusion and or administration. I understand that Home Help IV Infusions services are not meant to diagnosis, treat or cure.

  • Methylcobalamin B12
    $20 Increase energy and mental focus, and boost mood.
  • Vitamin B-6
    $20 Important in maintaining the health of our nerves, skin, and red blood cells. Boost metabolism, mild diuretic, and help flush the kidneys to reduce water weight. Boost mood and reduce anxiety.
  • Vitamin D3
    $20 Improve mental health, reduce inflammation, improve immune system and heart health.
  • Tri-Immune Boost
    $20 Enhance your immune system to help fight infections such as the cold and flu.
  • Toradol
    $30 Anti-inflammatory, pain reducer NSAID
  • MICC (Weight Loss Support)
    $25 Fat burning and appetite suppressant to aide in a weight loss journey.
  • Lipo Mino Weight Loss Support
    $35 Helps to break down sugars and carbohydrates and convert them to energy, convert fat to energy, increase metabolism, and support immune system.
  • Mineral Blend
    Mineral Blend - $20 Nervous system health, memory, learning, immune health and, wound healing
  • Taurine
    $20 Helps support nerve growth, lower blood pressure, improve liver function.
  • Amino Blend
    $20 Support new muscle growth, increase blood flow, help absorb calcium, boost energy and increase endurance.
  • Biotin
    $20 This vitamin is important for overall health, and plays a role in cell growth, carbohydrate metabolism, and fatty acid synthesis. Healthy skin, hair and nails.
  • NAD + - 50 MG OR 100 MG
    $60/$95 Improves mental clarity and focus. Promotes cell regeneration, slows aging, boosts metabolism, increases energy and reduces inflammation, helps with anxiety, depression and PTSD
  • Glutathione
    $20 Can improve psoriasis, and improve insulin resistance. Prevention of cataracts, glaucoma, aging, alcoholism, cancer, heart disease, liver disease, lung disease, Alzheimer’s disease, Parkinson’s disease, osteoarthritis, diseases that break down the body’s immune system.
  • Battery Pack Combo Injection
    $45 Made for cellular energy, mental clarity and overall health. Great way to jump start your enery and get you feeling your best.
  • Jet Pack Combo Injection
    $60 Step up and maximize energy, mental clarity and focus. This is a step up from our Battery Pack.
  • Body Burner Weight Loss Combo
    $45 Made to aide and jumpstart you in your weight loss journey, increase energy, burn fat and increase metabolism.
  • Body Burner Plus Weight Loss Combo
    $60 Step up from Body Burner this will aide and jumpstart your weight loss journey, help convert food to energy by breaking down sugars and carbohydrates, convert fat to energy, support the immune system and increase energy.
  • Glamorizer Combo
    $60 Look and feel great this is made to support healthy hair, skin, nails, eyes and liver with anti aging benefits to help you be your best YOU.

Thank you for submitting the form. Now go schedule your appointment.

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