First Name *

Last Name *

Date of birth *

Phone *

Email *

What services are you getting today?

Hot Flash Rescue Infusion

Myer's Cocktail Infusion

The Energy Boost shot (B12)

LipoLuxe metabolism shot (MIC+B12)

The Power shot (B complex)

Radiant Flow recovery/performance shot (Amino Acid blend)

Cellular Longevity Recharge shot (NAD+)

Not sure

Must Check All (If questions please inform clinician) *

I am NOT pregnant or breastfeeding

I have NO known severe allergy to B vitamins, vitamin C, zinc, cobalt, or injection preservatives

I have NO history of severe kidney disease, uncontrolled heart disease, or current fever/infection

I received and understood today’s aftercare instructions

Consent *

I have reviewed the information provided, answered the health questions truthfully, and I voluntarily consent to receive an intramuscular vitamin injection today from D’NuVi Wellness & Hydration, administered by a licensed clinician under medical oversight. I understand the potential risks (injection-site pain/bruising/bleeding, infection, allergy, dizziness/fainting, nerve injury, and rare serious reactions). I understand this is elective wellness care and not a substitute for medical diagnosis or emergency treatment; my questions were answered; I may refuse/stop at any time; and I will seek urgent care/911 for concerning symptoms after my visit. I authorize the creation/storage of my medical record and agree to be contacted for necessary follow-up related to today’s service.

Consent *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested from D’NuVi. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Consent *

All infusion and injection services require review of your health history and intake form before treatment. Completing this form does not guarantee eligibility for treatment. Final approval will be determined after your intake has been reviewed. I understand that my requested service is subject to medical review and approval.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others from D’NuVi. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Injection Intake & Consent