Schedule An Appointment "*" indicates required fields 1Pick A Package2Age Verification3Patient Information4Pick An Appointment Time IV Packages*Please select your desired IV package from the list below. B12 Injection Power Hour Cold & Flu Hangover Cure All American Kardashian Pick Me Up Project X Myers Mega Myers Would you like to add additional items to your IV package?You may select one or more. The Raider Rehab team will let you know if any changes should be made based on your selections. These items are optional. B-12 Injection $20 Biotin $30 Fluid $40 Glutathione $20 Magnesium Sulfate $40 Multivitamin $45 Pepcid $25 Thiamine $35 Toradol $20 Vitamin C $20 Zofran $20 Is the individual receiving the IV service at least 18 years of age?* Yes No Unfortunately, we are only able to provide mobile IV services to individuals that are at least 18 years of age. We apologize for any inconvenience. Legal Name*Please provide your name as it appears on your government issued photo identification. First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where Should Your Mobile IV Service Be Performed?* The address above I would like to specify a different address Street Address For IV Service* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Medical History*Please check the appropriate conditions based on your current medical history. Type 1 Diabetes Type 2 Diabetes Congestive Heart Failure None of the items above Special NoteIf you have a note or special request regarding your IV package that you would like to pass along to the Raider Rehab Team, please let us know! Appointment*Please use our calendar to find instant availability for your appointment. Then, click on Schedule Appointment. Your selected appointment time will be automatically released after 10 minutes until you click on Schedule My Appointment.CommentsThis field is for validation purposes and should be left unchanged.
