At Home Vitamin Shot PreQualification

Please enable JavaScript in your browser to complete this form.

What Is Your Gender

What is your gender? *

Male
Female

Go Back

Medical History

Do you have any known allergies? *

Please list your allergies: *

Have you ever experienced an allergic reaction to a vitamin injection or supplement? *

Please describe: *

Do you have any chronic medical conditions? (e.g., diabetes, heart disease, kidney or liver issues) *

Please list: *

Are you currently taking any prescription medications, over-the-counter drugs, or supplements? *

Please list: *

Have you had surgery or a significant medical procedure in the last 12 months? *

Please describe: *

Vitamin-Specific Screening

Have you previously received vitamin injections or IV therapy? *

What type(s) and when? *

Do you have any history of sensitivity to injections or difficulties with needles? *

Please explain: *

Are you currently pregnant or breastfeeding? *

Do you have any history of blood disorders (e.g., anemia, clotting disorders)? *

Please describe: *

Have you been diagnosed with or treated for neurological conditions (e.g., neuropathy)? *

Injection-Specific Questions

Do you have any skin conditions (e.g., rashes, infections) that might affect injection sites? *

Please describe: *

Do you currently experience swelling, redness, or tenderness at prior injection sites? *

Have you recently been diagnosed with or experienced symptoms of an infection (e.g., fever, chills)? *

Are you comfortable following at-home injection instructions, including proper storage and disposal procedures? *

Lifestyle & Goals

What is your primary goal for receiving vitamin injections? *

Energy enhancement
Immune support
Weight management
Skin health
Other

Please specify your primary goal: *

How often do you plan to use at-home vitamin injections? *

Weekly
Bi-Weekly
Monthly
As needed

Consent & Acknowledgement

I confirm that the information provided is accurate to the best of my knowledge. *

I understand the risks associated with at-home vitamin injections, including potential side effects and the importance of following all provided instructions. *

I have reviewed and agree to the storage, handling, and disposal requirements for at-home injections. *

I consent to participate in this at-home vitamin injection program under the guidance of the medical team. *

Contact Information

Name *

First

Last

Date of Birth *

Email *

to medications, (e.g.,

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Select Your Service

What Is Your Gender

Medical History

Vitamin-Specific Screening

Injection-Specific Questions

Lifestyle & Goals

Consent & Acknowledgement

Contact Information

Contact Us

Locations

Resources