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Prescribing Provider Notes:
Patient consulted with prescribing provider via TELEMEDICINE:
Patient consulted with prescribing provider IN PERSON:
Standing Order for Return Visit
Full Chart Order
Normal Saline
Amino Blend
Banana Bag (Infuvite)
Benadryl (Diphenhydramine)
Biotin
Caffeine Citrate
Compazine (Prochlorperazine)
Dexmethasone
Glutathione
Lipo-C
Magnesium Sulfate
MICC
NAD +
Pepcid (Famotidine)
Reglan (Metoclopramide)
Taurine
Tri-Immune Boost
Toradol (Ketrorolac)
Vitamin B-Complex
Vitamin B5 (Dexpanthenol)
Vitamin B6 (Pyridoxide)
Vitamin B12 (Hydroxocobalamin)
Vitamin C (Ascorbic Acid)
Zinc Chloride
Zofran (Ondansetron)

Revitalize Provider Initial and Standing Order Form IV Therapy Medical Form

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Published: Dec. 29, 2025, 5:12 p.m.
Provider: Dr. History Physical
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