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Revived Body - Mobile IV Therapy
Intake Form

All customers must complete this Intake Form before receiving an IV from Revived Body

Client Intake Form

Please fill out the following form in order to participate in our services
Gender
Why are you seeking IV infusion or injection therapy?

Please check any conditions that apply to you:

CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL AND URINARY
METABOLIC/ENDOCRINE/AUTOIMMUNE
NEUROLOGIC
HEMATOLOGY
MUSCULOSKELETAL
PSYCHOLOGICAL

WOMEN (non menopausal)

Are you currently breastfeeding?
Any chance of pregnancy?
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