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 TEST DATE *

MM

DD

YYYY

COVID-19 TESTING

Rapid Antigen COVID-19 Test ($100 / $175)

RT-PCR COVID-19 Test ($100 / $175)

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

In the past 14 days, have you been in close physical contact with anyone who is confirmed to have COVID-19 or has symptoms consistent with COVID-19? *

YES

NO

Are you currently isolating because you may have been exposed to a person with COVID-19 or are worried that you may be infected with COVID-19? *

YES

NO

Terms of Service *

COVID-19 TESTING: If you are experiencing COVID-19 symptoms, you may ONLY book your rapid COVID-19 test via mobile and CANNOT get tested at our Hoboken or Asbury Park Drip Lounge locations. DRIP LOUNGE LOCATIONS: ‣ Please note that while 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. ‣ $100 fee will be charged if our nurse arrives to your appointment and does not render the service. CANCELLATIONS: ‣ WE REQUIRE AT LEAST 24-HOUR ADVANCE NOTICE OF CANCELLATION. IV Elements understands that situations may arise that require you to cancel or postpone your appointment. We kindly request 24-hours notice be provided if you need to cancel or reschedule your appointment. ‣ If you book your service less than 24-hours in advance, there is a $100 cancellation fee. 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