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 Email (required)

Your Phone Number (required)

Your Company/Facility Name (required)

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

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 may constitute an automatic change in orders to a Midline or may require you the ordering provider to obtain an order for an x-ray and to followup on the x-ray results (Active AFib or other disqualifying cardiac arrhythmia, Inability to advance the catheter to the Superior Vena Cava during insertion)

A-Fib Aknowledgement (required)

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 60 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.