Will you take a few minutes to complete this brief health survey in order to schedule your first IV?
Yes!
 
What's your name? *

 
How did you hear about OptimalSelf MD's IV Therapy? *

 
Have you ever had a vitamin IV? *

     
 
Did you experience any negative reactions? *

     
 
What kind of reaction did you have? *

 
Are you on any prescription medications? *

     
 
Please list them here:

 
Do you have any allergies? *

     
 
Please list them here and describe your reactions: *

 
Do you have a history of any of these conditions: kidney disease (also called renal dysfunction), elevated creatinine, electrolyte imbalance (sodium, potassium, calcium, or magnesium), congestive heart failure, arrythmias (also called tachycardia, bradycardia, SVT, or palpitations), G6PD deficiency? *

     
 
Are you currently experiencing any symptoms of illness? *

     
 
Are you currently pregnant or is there any chance you might be? *

     
 
Thanks for your time, but since you answered "Yes" we do not advise any IV therapy at this time.  Pregnancy is a time of enhanced sensitivity to high doses of vitamins, which is why prenatal vitamins are very carefully formulated. If you determine you are not pregnant, feel free to return to this form and re-apply. If you are pregnant, be aware that in the stressful and physically demanding post-partum period,  vitamin infusions can help restore energy! Please contact the office for any questions:
864-214-5232

Thanks! If you've made it to this page, you're good to go. Book your appointment by registering as a patient and selecting the time that works best for you! Contact the office with any questions: 864-214-5232
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Since you answered "Yes", we will need to talk before you can safely have IV Therapy! Schedule a call here:
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