Provider Referral Program

Referring Provider Information:

Name(Required)

First Last

Phone(Required)

Email(Required)

Contact Preference(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Your Patient/Client Information:

Name(Required)

First Last

Sex(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Contact Preference(Required)

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

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.

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:

Confirm you are real(Required)

(Select “I’m a person” and complete the Google Captcha to send the form.)

reCAPTCHA Validated