IV FLUIDS form

NOBLE PHYSICIANS MEDICAL GROUP

Mobile IV Hydration & Infusion Services

IV HYDRATION INTAKE, CONSENT & PAYMENT AUTHORIZATION FORM

PATIENT INFORMATION

Full Name:

Date of Birth:

Phone Number:

Date of Service:

SELECT ONE IV TREATMENT

Dehydration 500mL (0.9% Saline) — $249
Dehydration 1 Liter (0.9% Saline) — $299
Myers Cocktail IV Treatment — $299 (500 mL)
Includes IV fluids, vitamins, electrolytes, and antioxidants Ingredients: B-Complex Vitamins, Vitamin B12, Vitamin C, Magnesium IV
Migraine / Headache Relief — $349
Includes Magnesium and Toradol
Stomach Flu — $299
Includes: B-Complex Vitamins, Vitamin B12, Vitamin C, Pepcid, Zofran
Hangover Relief — $299
Includes: B-Complex Vitamins, Vitamin B12, Vitamin C, Toradol, Zofran
NAD IV Therapy — $799
Supports anti-aging, energy, brain function, and addiction recovery
Glutathione Boost — $399
Powerful antioxidant supporting immune system, liver detoxification, skin rejuvenation, and energy
Iron Infusion (Venofer) — $799
For patients with iron deficiency, administered in the comfort and convenience of your home

PAYMENT INFORMATION

Name on Card:

Credit Card Number:

Expiration Date (MM/YY):

CVV (Back 3 Digits):

SIGNATURE

Patient Signature:

Clear Signature

Birth: (MM/YY): Expiration

Date:

What Our Patients Say

Dr. Lalezari is incredibly thorough and patient. He took the time to explain my results and made sure all my questions were answered. I finally feel like I have a doctor who actually listens.

Maria G.

I used the house call service for my elderly parent, and it was exceptional. The visit was prompt, compassionate, and comprehensive—truly hospital-level care at home

Luis M.

The staff is friendly and welcoming, and the doctor really takes time with you. I never feel rushed, and he always provides clear explanations and next steps

Rebecca T.

The office is clean, organized, and efficient. I was seen on time, and the entire visit—from check-in to labs—was smooth. Highly recommend for anyone looking for a great primary care doctor in Los Angeles.

James L.

I scheduled a telemedicine visit and it was so convenient. Dr. Lalezari was attentive and professional, and I received my follow-up instructions right away. Five-star experience.

Sofia & Daniel R.

Amazing care! He found an issue during a routine physical that other doctors had missed. I’m very grateful for his attention to detail and expertise.

Anthony P.

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Your Partner in Long-Term Health

Whether you’re seeking preventive care, managing a chronic condition, or looking for a trusted internal medicine physician in Los Angeles, Dr. Lalezari is here to help.