GET AN IV NOW

GET AN IV NOW is a service for clients of IV Solutions Inc.

Please complete the form below and an IV Solutions client services representatives will contact you within 30 minutes to schedule the service requested. If you do not hear from a client services representative within 30 minutes please call 844-848-8326 and dial ext 1 for our Clinical Services Hotline.

 

CONTACT INFORMATION

Your First and Last Name - (required)

Your Facility Name (required)

Specialty Facility Code - If N/A select NONE (required)

Your Phone Number (required)

Your Email address for reply confirmation

PATIENT INFORMATION

Patients Initials - do not use patients full name (required)

Patients street address include City and State (required)

Patients phone number (required)

Allergies - May select multiple - (required)

Allergies Other

PHYSICIAN ORDERS

Is there an active signed licensed independent practitioner order - if no please obtain order before continuing (required)

Service Requested (required)

Please note: If a PICC is requested the following concerns would constitute an automatic change in orders to a Midline (Active AFib or other disqualifying cardiac arrhythmia, Inability to advance the catheter to the Superior Vena Cava during insertion)

SCHEDULING

Please note our regular hours of operation are Monday - Friday 08:00 to 17:00 - any requests outside of normal business hours will be received and responded to the next business day.

Although we will do our very best to see patients at the preferred or requested time, all requests will be scheduled based on geography, clinician availability and patient availability.

Completion of this form does not guarantee services as this form is a request for scheduling. A scheduler or clinician will call, email or text with confirmation of the case to the number or email provided. If you have an urgent matter after normal business hours or you do not hear from us within 45 minutes of sending this form please call 844-848-8326 and select option 1

Date Requested (required)

Time Preference - Please note (required)

Comments / Notes

To complete this form you must complete all required items and successfully complete the equation below - Once complete and accepted, you will receive a green bar noting your message was successful. Otherwise a red bar with other instructions will appear at the top of the form.

File upload - You may attach physician orders up to 10MG - Maximum of two pages no cover sheets please. PDF ONLY. Otherwise please fax orders to 844-848-8326. Please note patient will not be scheduled until orders are received

Please complete the equation below for verification