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Fountain of Youth
Hangover Helper
Hydrate
Hydration Plus
Immunity Defense
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NAD+
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Trim Life
Vitamin C
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Provider Referral Program
The Good Life
May 30, 2024
June 18, 2024
Provider Referral Program
Referring Provider Information:
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Contact Preference
(Required)
Select
Email
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Your Patient/Client Information:
Name
(Required)
First
Last
Sex
(Required)
Select
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
Phone
(Required)
Email
(Required)
Contact Preference
(Required)
Select
Email
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date and reason for most recent visit with provider:
(Required)
Specific IV therapy recommendation for this client?
Yes
No
Select an IV Therapy you recommend for your Patient:
Reference The Good Life IVs
. Also, we offer a variety of Add-on ingredients and/or Booster Shots. Upon submittal of an Appointment Request and review of your patient’s Intake Form, our staff and Medical Director will assess requests for any Add-ons and/or Booster Shots.
Select IV
Activate (Electrolyte Fluids, Vitamin C, B1, B2, B3, B5, B6, Glutamine, Arginine, Ornithine, Lysine, Citrulline, B12)
Beautify (Electrolyte Fluids, Vitamin C and Glutathione)
Fountain of Youth (Electrolyte Fluids, Vitamin C, B1, B2, B3, B5, B6, B12, Biotin)
Hangover Helper (Electrolyte Fluids, Zofran, B1, B2, B3, B5, B6, Magnesium, Zinc, Manganese, Copper, B12)
Hydrate (Electrolyte Fluids)
Hydration Plus (Electrolyte Fluids, Vitamin C, B1, B2, B3, B5, B6, Magnesium, Zinc, Manganese, Copper)
Immunity Defense (Electrolyte Fluids, Vitamin C, B1, B2, B3, B5, B6, B12, Zinc)
Mr. & Mrs. Myers (Electrolyte Fluids, Magnesium Chloride, B1, B2, B3, B5, B6, B12)
NAD+ (250mg or 500mg)
Prime Mind (Electrolyte Fluids, B6, B12, Taurine, Alpha-Lipoic Acid)
Recovery-2-Perform (Electrolyte Fluids, Vitamin C, B1, B2, B3, B5, B6, Glutamine, Arginine, Ornithine, Lysine, Citrulline, Magnesium, Zinc, Manganese, Copper)
Relie (Electrolyte Fluids, Calcium Chloride, Magnesium Chloride, B1, B2, B3, B5, B6, B12)
Trim Life (Electrolyte Fluids, Taurine, B1, B12, B3, B5, B6, B12)
Vitamin C (5 gm, 10gm, 15gm, 20gm, 25m)
Additional input regarding your recommended IV (dosage, concerns, etc.):
Please advise as to reason for IV referral so we can best care for your Client:
How many IV’s are you recommending for this client?
How Often?
Pertinent health history and/or laboratory results:
Any additional information it is important for us to know:
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