IV MD Hydration, Oxygenation, Rejuvenation, Mobile IV

Membership Enrollment

Online Membership Enrollment Form

Choose Preferred Membership Option:

Member First Name:

Member Last Name:

Gold / Purple Membership Guest Name (optional):

Guest Phone (optional):

Member Email:

Member Phone:

Credit Card Number:

Expiration:

CVC:

Billing Street Address:

Apt./ Suite/ Unit #:

City:

State:

Zip Code:

Opt-In

By checking this box, I agree to the online enrollment of the selected IV MD Membership. I agree that I am an authorized user of the provided bank account information provided here within. I agree & authorize IV MD to use the provided personal information to process this one time charge and any ongoing monthly subscription charges to maintain my active membership status. I will not hold IV MD, LLC, employees or any affiliates of IV MD, LLC responsible, or seek any legal action for any reason for personal or financial damages that may occur from this transaction. I agree to the aforementioned by checking opt-in and that all information provided within this document is valid and true to the best of my knowledge. Please refer to our payment policy for more information.

First Name:

Last Name:

Todays Date:

Time:

Date of Birth:

*Online enrollment may take 24-72 hours (1-3 business days) for processing.

You will be emailed a confirmation of your enrollment. Once the payment and membership are approved we will contact you. Then, you may present to your nearest IV MD location to pick-up your new IV MD membership card. to retrieve your newly issued membership card, please bring a copy of the emailed sales receipt and a state issued ID / Drivers License to confirm patient identification. Thank you and congratulations on your newly selected IV MD Membership status.

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All services provided have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. The material on this website is provided for informational purposes only and is not medical advice. Always consult your physician before beginning any treatment or therapy program. Any designations or references to therapies are for marketing purposes only and do not represent actual products.