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ABOUT US
ABOUT US
MEDICAL SERVICES
Physical
Gyenocology
Urgent Care
Vaccines
IV THERAPY
How It Works
IV DRIP MENU
Concierge Services
WELLNESS
Weight Loss Program
Covid Antibody Testing
Blood Draw Testing
Hormonal Therapy Treatment
Urgent & Chronic Virtual Consultations
House Calls
CONTACT
Renew Medspa Wellness
Please fill out the following form
First name
Last name
Email
Date of Birth
Have you been told that you need to start dialysis or are you currently on dialysis?
No
Yes
Are you taking or have you been told you need to take Digoxin?
No
Yes
Are you of African, Midde Eastern or Asian descent? (G6PD screening fo Vitamin C infusion)
No
Yes
Have you been told you have a decreased GFR or kidney problem?
No
Yes
Do you have any of the followng conditions?
End Stage Renal Disease
Myasthenia Gravis
Myxedema
Cerebal Hemorrhage
HYPERmagnesium
Current UTI
HYPERparathyroidism
Kidney/Renal Disease
Cardiac Arrhythmia
G6PD Deficiency
Hemolytic Anemia
Low Blood Pressure
CHF (Congestive Heart Failure)
If you answered yes to any question, please elaborate
Initials
I declare that the info I’ve provided is accurate & complete
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