(202)-834-8225
Hydraboostivtherapy@gmail.com

Instagram

Home
About Us
Services
Book Now

Book Now

Our Services

HydraBoost IV Therapy

Personal Information

Patient Name

DOB

MM slash DD slash YYYY

Address

Apt#

City

Address

State / Province / Region ZIP / Postal Code

Cell Phone

Home Phone

Sex

Male

Female

Emergency Contact Name

Phone #

Reason for your visit today?

Known Drug Allergies?

Yes

If yes, please list

List all medications you are taking (prescription and OTC):

Do you take Aspirin, Advil, Motrin, Ibuprofen or anti-inflammatory medication more than once per week

Yes

If yes, please explain

Do you smoke:

Yes

If Yes How many per day

for how many years

Do your drink alcohol:

Yes

If Yes How much

How often

Are you currently pregnant?

Yes

Please list any concerns you have

Please review the following consent forms before proceeding:

HIPAA Notice(Required)

I agree to the HIPAA Notice of Privacy Practices. Read more.(Required)

Consent for Photography(Required)

I agree to the Consent for Photography, Videography, and Recording. Read more.(Required)

Product Name(Required)

Payment Method

American Express

Discover

MasterCard

Visa

Maestro

Supported Credit Cards: American Express, Discover, MasterCard, Visa, Maestro

Card Number Expiration Date Security Code Cardholder Name

HydraBoost IV Therapy offers personalized hydration and wellness treatments, right to your door. Serving Washington, DC, and a 10-mile radius with on-demand care for hydration, immunity, recovery, and more.

Quick Links

Home
About Us
Services
Book Now

Services

Get Up and Go
Immunity Boost
Inner Beauty
Myers Cocktail

Contact Details

Hydraboostivtherapy@gmail.com
(202)-834-8225

Instagram

Scroll to Top