Schedule an IV drip

First Name

Last name

Treatment Location Zip Code*

Mobile Number

Who will be receiving treatment?

Self Someone else

Is the person to be receiving treatment's information entered in fields above (Name, Email, Phone)?

Yes No

Client's Date of Birth

Please select ALL of the following that apply to the client:

I have been diagnosed with or told I have congestive heart failure (CHF) I am on dialysis I have a history of uncontrolled bleeding I have been diagnosed with or told I have pulmonary arterial hypertension (PAH) I have impaiment preventing myself from making medical decisions and/or consenting to my treatment None of these

When would you like to request your appointment?

ASAP (first available appointment) Scheduled time/date

Preferred Date

Preferred Time

Where would you like you treatment?

Street address

City

State

Zip code

How many clients need treatment?*

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I agree to the Privacy Policy, and Cancellation Policy.

I understand that Medizen does not directly provide medical services, but helps schedule appointments with a licensed medical provider (the “Medical Provider”) who will perform the requested procedure(s). I understand that the information I provide will be shared with the Medical Provider, who will review my medical history, determine if the procedure(s) are appropriate, and perform or oversee the treatment based on their professional judgment. I confirm that all medical, medication, and personal information I have provided is true and accurate to the best of my knowledge. I understand that it is my responsibility to inform Medizen and the Medical Provider of any current or changing health conditions and to update my information as needed. I understand that providing accurate and up-to-date medical information is important for safe and appropriate treatment.