Infusion Bar Form Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Infusion Bar Service Vitamin D3 $20 Vitamin B12 $20 Lipo $25 Hydration Drip $99 Custom Iv Drip $100 ( $25 per ad on) Immunity Boost drip $125 B- Lean Drip $175 Boost Drip $175 ( our version of the Myers Cocktail) Beauty Drip $175 Hangover Relief Drip $200 Migraine Relief Drip $225 NAD $300 Infusion Ad ons $25 each * ( choose only if you selected custom drip) Vitamin C Boost Glutathione Push B Complex Zinc Boost Anti Nausea Medication Preferred Date MM DD YYYY Time preffered * Hour Minute Second AM PM How did you hear about us? Option 1 Option 2 Message * ( additional information we might need to know before your appointment) Thank you!
