Book Mobile IV Dispatch | Clear Choice IV & Rejuvenation

What happens next

Dr. Dourra reviews your intake
If approved, eRx is routed to Clear Choice Pharmacy (Michigan)
Pharmacy prepares your IV → RN dispatched to your location

Your Selection

Basic Hydration$149

Mobile travel & dispatch$50

Estimated Total$199

Drip subtotal: $149

Contact Information

First name *

Last name *

Email *

Mobile phone *

Mobile Dispatch Address

Where should our licensed RN meet you?

Street address *

City *

State *

ZIP code *

Preferred Appointment Time

Preferred date (optional)

Time window *

ASAP — dispatch when available

Morning (8am – 12pm)

Afternoon (12pm – 5pm)

Evening (5pm – 8pm)

Brief Health Screening

Required before RN dispatch

Kidney disease? *

Yes

Heart condition? *

Yes

I am pregnant, planning pregnancy, or breastfeeding

Allergies

Current medications

Special instructions for the RN

Identity & Payment

Upload your ID and authorize payment before submission.

Identity Verification

Secure ID storage

Your ID is encrypted and stored in HIPAA-eligible storage. It is used only for telemedicine identity verification.

Photo ID - Front *

Click to upload front of ID

Photo ID - Back *

Click to upload back of ID

Payment Authorization

Authorization hold — $199

Your card will be authorized for $199. Funds are captured only after provider clinical approval.

Preparing secure payment...

Telemedicine Consents & Acknowledgments

Required before your intake is submitted for provider review.

I understand that my medication is prepared in a compounding pharmacy in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider.

I Agree

NO RETURNS

I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY AVAILABLE AT https://clearchoicepharmacy.com/refund-policy. I authorize Clear Choice Pharmacy to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

I Agree

I agree to give my consent to treat. I have read the Telehealth Consent located at https://clearchoicepharmacy.com/telehealth-consent.

I Agree

I agree to Clear Choice Pharmacy's Terms and Conditions. I have read the Terms and Conditions located at https://clearchoicepharmacy.com/terms-and-conditions.

I Agree

I understand my health information will be handled in accordance with HIPAA regulations. I have read the Privacy Policy located at https://clearchoicepharmacy.com/privacy.

I Agree

PRINT NAME — I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN (First and Last Name) *

I authorize a payment hold of $199 to be charged only upon prescription approval *

Prefer to call? 1-248-987-6182

Novi, MI (248) 987-6182Fax: (248) 987-4963

Clear Choice Rx

Complete Your IV Order

Identity Verification

Payment Authorization

Telemedicine Consents & Acknowledgments

Complete Your IV Order

Identity Verification

Payment Authorization

Telemedicine Consents & Acknowledgments