Intravenous Vitamin C Assessment
Please complete this assessment to help us determine your eligibility for IV Vitamin C therapy.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any of the following medical conditions? (Select all that apply)
*
Kidney disease or impairment
G6PD deficiency
History of kidney stones
None of the above
Other
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Fever
Cough
Shortness of breath
Fatigue
None of the above
Other
Please briefly describe your reason for seeking IV Vitamin C therapy.
*
Preferred Appointment Date and Time
*
Submit Assessment
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