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The information entered on this form must reflect the person that is going to be receieving treatment by Mobile IV Medics 

Please verify the client's information (person receiving treatment) is entered above and that persons information is entered subsequently for the resepective questions on this form

You have indicated that the information entered on this form is someone other than the person to be receiving treatment. The information entered on this form must be for the client. Please update the Name, Email, and Phone Number above to reflect the client's information

Failure to do so will result in delays and/or denial for treatment

You have selected that the client is unable to consent to treatment. All clients consulted on and treated by MIVM must be able to consent to receiving treatment themselves

Exceptions may be considered with an infusion treatment order from the clients primary care or other managing medical provider. Additional details regarding necessary next steps will be provided following your submission of this form

Pulmonary arterial hypertension PAH is a rare disease specifically affecting the pulmonary arteries. This is NOT the same as general hypertension (HTN) or heart/coronary artery disease (CAD).

We will try our best to take care of you as soon as possible! Our standard hours of operation are 8AM to 8PM, 7 days a week, but we may be able to help you during off hours.

Please be on the lookout for communication regarding your appointment scheduling shortly.

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Your Location - {azPhysical}, {azFull287} {ZC}

Thanks for your interest in services provided by Mobile IV Medics. Unfortunately, we do not currently provide services at your location ({azPhysical}, {azFull287} {ZC}).

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If you believe you have reached this page in error, please press the back button on the bottom left of your screen and correct your Zip Code on the first page of this form. If you still need assistance, please give us a call or text at (833) 483-7477.