Schedule IV Therapy Appointment First Name *: Last Name *: Email *: Phone *: Treatment LocationPlease tell us the address where you would like to receive your treatment. Address 1 *: Address 2 : City *: State/Province *: Zip/Postal Code *: Desired Appointment Date*: Desired Appointment Time*: IV / Bag Type*: —Please choose an option—MYER’S CocktailHangover RescueEnergy BoostAthletic BoostAthletic RecoveryThe Original Immunity BoostBanana BagUltimate Immunity BoosterMenopause BagPregnancy Hydration BagPregnancy Immunity BoosterPlain Normal Saline Number of Treatment Recipients *: Please review, print and scan the documents below and have them ready for your nurse at your appointment: Pre-Treatment Medical Questionnaire Consent to Treat