NAME *

First Name

Last Name

DATE OF BIRTH *

MM

DD

YYYY

IF MOBILE, PLEASE PROVIDE YOUR ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PREFERRED DATE *

MM

DD

YYYY

WILL YOU BE APPLYING AN IV PACKAGE TO YOUR SERVICE(S)?

For services at the Hoboken Drip Lounge and Asbury Park Drip Lounge locations ONLY.

Yes

No

IV VITAMIN THERAPY SERVICES

Hair, Nails & Skin ($234 Location / $319* Mobile)

Hangover Rescue ($204 Location / $289* Mobile)

Hydroboost ($144 Location / $289* Mobile)

Immunity Support ($224 Location / $309* Mobile)

Limitless All-in-One ($274 Location / $359*)

Migraine Relief ($194 Location / $289* Mobile)

Mind & Body ($254 Location / $339* Mobile)

Myers Cocktail ($174 Location / $289* Mobile)

Performance Recovery ($214 Location / $299* Mobile)

Skin Brightening ($184 Location / $289* Mobile)

Super Myers Cocktail ($264 Location / $349* Mobile)

Weight Loss Fat Burner ($244 Location / $329* Mobile)

VITAMIN BOOSTERS

Amino Acids (Tri-Amino) ($40)

Anti-Nausea Boost ($25)

B12 IM Blast ($20)

B-Complex ($20)

Beauty Blast ($85)

Biotin ($35)

CoQ10 Boost ($35)

Calcium ($35)

Folic Acid ($75)

Glutathione Push ($50)

Headache Helper ($30)

L-Carnitine ($35)

Lipotropic Shot ($60)

Magnesium ($35)

MIC ‘Slim’ Shot ($40)

Oxygen Boost ($20)

Taurine ($35)

Trace Elements ($60)

Vitamin C ($25)

Vitamin D ($35)

Zinc ($40)

50mg NAD+ Boost ($90)

100mg NAD+ Boost ($160)

BR+ NAD THERAPY

BR+ NAD 250mg ($329)

BR+ NAD 500mg ($490)

BR+ NAD 750mg ($680)

BR+ NAD 1,000mg ($860)

BR+ NAD 1,500mg ($1,100)

BR+ NAD 3-Day ($1,470)

BR+ NAD 6-Day Program ($6,500)

BR+ NAD 10-Day Program ($12,500)

BR+ NAD 15-Day Program ($16,750)

The Bridge Device ($1,200)

The Bridge Device 10-Day Program ($12,500)

SPECIAL IV SERVICES

High Dose Vitamin C ($214 - $384)

Mistletoe Therapy ($400 - $410)

Chelation Therapy ($450)

HCG Diet ($125+)

Testosterone Replacement Therapy ($125+)

Holistic Health Coaching ($100)

Monoclonal Antibody Therapy (Price TBD)

Evusheld Pre-Exposure Prophylaxis ($599)

Have you experienced any of the following symptoms in the past 48 hours? *

‣ Fever or chills ‣ Cough ‣ Shortness of breath or difficulty breathing ‣ Fatigue ‣ Muscle or body aches ‣ Headache ‣ New lost of taste or smell ‣ Sore throat ‣ Congestion or runny nose ‣ Nausea or vomiting ‣ Diarrhea

YES

NO

Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?* *

YES

NO

Have you traveled internationally in the last 10 days? *

YES

NO

Are you currently waiting on the results of a COVID-19 test? *

YES

NO

Terms of Service *

****Please note, mobile in-home or in-office prices below include 15-30 minutes from our physical location, extra mobile fee based on time, distance, and gas prices. In addition, any IV vitamin therapy service will incur a $100 surcharge for those within 5 days of a positive COVID-19 test.** DRIP LOUNGE LOCATIONS: ‣ Please note that the CDC no longer requires people to wear a mask indoors in the state of New Jersey, in order to do our part to keep our staff and clients safe, we are still requiring masks in all drip lounge locations. MOBILE ORDERS: ‣ When booking mobile appointments, you agree to pay IV ELEMENTS a 10% tip for the service booked. ‣ Payments will be charged once the appointment has been confirmed by a member of our team or at the time of service. CANCELLATIONS AND REFUNDS: IV Elements understands that situations may arise that require you to cancel or postpone your appointment. Please understand that such changes affect not only our staff but our other clients as well. - As such, we request that 24 hours’ notice be provided if you need to cancel or reschedule your appointment. - Failure to cancel or reschedule an appointment without 24 hours’ notice will result in a $100 fee. - For NAD appointments there is a $250 cancellation fee for appointments canceled or rescheduled within 24 hours. - LATE FEE (15 minutes or more): $70. Each additional 30 minutes will result in an additional $70 fee. - NO-SHOW FEE (lounges and mobile services): Failure to attend your appointment or give notice that you can no longer attend your appointment, during or after the duration of when your appointment was scheduled for, will result in a change of all services in-full that you were scheduled for. - You may cancel your appointments via any of the following means: telephone, email, or text message. REFUNDS: ‣ In the event that a package or series of treatments has begun, but does not fully complete, these services will be considered to have been rendered. Should you wish to discontinue your treatment in the midst of your package or series of treatments, you will not be refunded for the unused treatments.

*I agree to the Terms of Service