New Patient (IV Therapy)

Name*

Phone Number*

Email*

Have you received IV nutrition therapy in the past?
This refers to elective IV nutrition therapy in a clinic, not acute care treatment in a hospital.

Received IV nutrition therapy in the past?*

YES
NO

Were you referred to our IV therapy program from a provider at a different clinic?

Referred by another provider?*

YES
NO

Who is the provider?

Which track of our IV therapy program matches your current health needs?

Prevent & Promote: for those seeking preventative therapy, health promotion, and general wellness
Problem-focused: for those seeking to address a current health problem

Our IV therapy offerings include many options for single treatments as well as serial treatments. Depending on your health goals, our providers may decide a series of multiple treatments best matches your needs and we’d like to know how realistic that is for you. Let us know which of the following best matches how you will travel to Lenox, MA.

How you will travel to Lenox?*

Daily commute - I live locally and can make the drive in a single day
Travel and lodging - I do not live locally and would need to plan for overnight stays
Seasonal - I live locally for parts of the year and can consider commuting in a single day
Other (briefly describe)

Travel (Other):

If you have had any recent surgeries (within the last 3-6 months) or serious health conditions that we should be aware of please let us know in the initial phone appointment with us so we may investigate possible contraindications for treatment.

A few quick questions