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What Are We Treating?
Which IV Treatment/Test Would You Like?*
Have you been diagnosed with or told you have hemophilia?*
- Yes
- No
Have you been diagnosed with or told you have congestive heart failure?*
- Yes
- No
Have you been diagnosed with or told you have kidney/renal failure, chronic kidney disease, or are you on dialysis?*
- Yes
- No
Have you been diagnosed with or told you have myasthenia gravis?*
- Yes
- No
Have you been diagnosed with or told you have pulmonary arterial hypertension (PAH)?*
- Yes
- No
Have you experienced fluid build up in your feet, legs or abdomen?*
- Yes
- No
Is the Patient Capable of Making Their Own Medical Decisions?*
- Yes
- No
Does the Patient Have COVID-19 Symptoms?*
- Yes
- No
Fever, Coughing, Loss of Taste/Smell, etc.

Date Of Treatment*
We offer ASAP service during business hours.
Month
Day
Year
Preferred Time Of Treatment*
We will reach out to confirm your appointment.

: Hours

Minutes

AM/PM
Address For Treatment*
Street Address City State ZIP Code
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