Medical Record Signature

  • DRIP IV Lounge, LLC IV Success, PLLC 1020 Navarro St. San Antonio, TX, 78205 T: 210-998-2348 F: 210-998-2089 Email: [email protected]
  • Medical Record Signature Attestation Statement

  • I,
  • ,
  • hereby attest that the health history I have provided to IV Success, PLLC is factual and true to the best of my knowledge. I authorize the medical provider to utilize telemedicine for a health assessment thus allowing photography and videography during the assessment and prescribe intramuscular and/or intravenous fluids, nutrients and medications as deemed necessary in order to provide the proper patient care.
  • Date Format: MM slash DD slash YYYY