iDrip Therapy Intake Form
We will do our best to arrive at the date/time you request, but please be flexible if possible. You will receive a text/call from our RN/Medic to confirm the date/time. We will also do our best to send you the RN/Medic you request however we cannot guarantee their availability.
Yes/no
Choose One
Yes/no
Yes/no
I certify that the above information is correct to my knowledge and I have not omitted any details about my medical condition or medical history. I hereby release iDrip Therapy from liability, without limitation, from any injuries that occur to me as a result of not providing current and correct medical history information in this form. I consent to receive recurring automated marketing by text message through an automatic telephone dialing system. Consent is not a condition to purchase. STOP to cancel, HELP for help. Message and Data rates may apply.
Clear