Assessment | 7B

Full name

Phone number

Email Address

Street Address City State (currently only serving Idaho)

Date of Birth

Why are you requesting a vitamin infusion?

Have you had a vitamin infusion before?
Yes No

What symptoms are you experiencing?

When did your symptoms start?

What medications are you currently taking?

What vitamin supplements are you currently taking?

Do you have high blood pressure and/or diabetes?
Yes No

Do you take medicine for blood pressure or diabetes?
Yes No

Do you have any problems with your kidneys/liver or have kidney disease or liver disease?
Yes No

What are your allergies, if any?

Please give a brief medical history, including surgeries and procedures.

Where did you hear about 7B-IV?

Do you have a treatment preference?

Infusions

Meyer's Cocktail

High Dose Vitamin C

Restart/Reboot

Hydrating Electrolytes

Simply Saline

Immune Booster

Pain Relief (Migraine)

Inner Beauty

Brainstorm

Energy Booster

Athlete Recovery

Quench and Re-energize

NAD+ I

NAD+ II

Added Nutrients

Vitamin D

Glutathione

Vitamin B12

Vitamin Complex

Biotin

Injections

Glutathione

Vitamin B12

Vitamin Complex

Biotin

What are some days and times you are available?