Pre-Screening Form Required fields are marked * First Name* Last Name* Email* Phone Number* Date of Birth* FemaleMalePrefer not to say Gender* Occupation* Complete Home Address* Desk JobSomewhat activeVery active What is your activity level?* Any allergies? Type N/A if none.* PCP Name (Primary Care Clinician)* List your current medications. Write N/A if none.* List any vitamins or over-the-counter medications you are taking. Write N/A if none.* YesNo Are you on blood thinners?* YesNo Are you breastfeeding?* YesNo Are you pregnant?* Any past surgical history? Write N/A if none.* FibromyalgiaChronic fatigue syndromeLiver or kidney problemsHeart ProblemsHypertensionThyroid issuesPre/Peri/post menopauseAny history of fainting spellsNONE Do you have any of the following conditions? Select all that apply.* IV VITE LLC does not participate with any health insurance company. A receipt/invoice can be only provided to me which I can submit to my insurance company if I wanna seek reimbursement from them. I am advised that vitamins are more naturals and most are not FDA-approved. I understand that my custom treatment is ordered for me. I agreed to be contacted to schedule my initial appointment and to pay the initial consultation fee of $130.00.* Yes. I want to proceed. I have read, understood and giving my consent to start the treatment.
