**Schedule Your Get Lean / Weigh Loss Mobile IV Therapy**

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Medical Screening

Please select ALL of the following that apply to you: *

I have been diagnosed with or told I have congestive heart failure (CHF)

I have been diagnosed with or told I have hemophilia

I have been diagnosed with or told I have kidney/renal failure or chronic kidney disease (CKD)

I am on dialysis

I have been diagnosed with or told I have pulmonary arterial hypertension (PAH)

I have a history of uncontrolled bleeding

I have impairment preventing myself from making medical decisions and/or consenting to my treatment

I currently have fluid build up in my feet, legs, or abdomen

I take medicine(s) for fluid retention (i.e. diuretic)

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