VIT Intake Form

Our clinical team is happy to speak with you about vitamin infusions for immunity boost, weight loss, or recovery. Simply complete the brief form below and a member of our team will be in touch to schedule your appointment.

Or check out our FAQs:

FAQs

Virginia Infusion Therapies IV Therapy Intake Form

Name

Date of Birth

I agree to the following terms set forth by Drs Marwan Jaber, Pranav Virmani, and Jay Kugler at Virginia Infusion Therapies.

I understand that the IV therapy services I will receive are considered alternative care and not a cure for any medical condition. As such, I understand that the IV therapies I will receive have not been cleared by the FDA.

I understand that Drs Jaber, Virmani, and Kugler and all other staff at Virginia Infusion Therapies are not providing me with a medical diagnosis or treatment for medical condition.

I understand and agree that Virginia Infusion Therapies staff members or representatives make no claims whatsoever, express or implied, regarding effects or outcomes of the IV therapy services provided to me.

I understand that all services I receive, including any physician involvement, are not covered by insurance and will not go toward my insurance deductible, and that Virginia Infusion Therapies will not file an insurance claim on my behalf. If I choose to pursue insurance reimbursement, I understand that Virginia Infusion Therapies will not provide assistance with my claim.

I am between the ages of 18 and 80.

Phone Number

Address

Email Address

Emergency Contact

Emergency Contact's phone number

Do you have any medicine allergies?

Yes No

Are you allergic to corn? (For high dose Vitamin C clients)

Yes No

Do you have any history of heart disease?

Yes No

Do you have any history of kidney disease?

Yes No

Are you pregnant?

Yes No NA

Are you breast feeding?

Yes No NA

Have you been told that you have problems with IV placement in the past?

Yes No

Have you ever had an adverse reactions to IV fluids?

Yes No

If you answered "yes" to any of the above, please explain further

How did you hear about Virginia Infusion Therapies?

By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

Your Initials

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Address:19500 Sandridge Way Suite 170, Leesburg, VA 20176
Phone:571-577-9048Opens in your application
Fax:571-577-9059
Email: info@virginiainfusion.comOpens in your application
Website:www.virginiainfusiontherapies.com

Clinic Hours
Monday-Friday: 9am-5pm
Closed Saturday & Sunday