Exclusive Event Intake

Event Intake & Wellness Check-In

Please complete this secure intake before your event visit so our team can prepare appropriately. Final service eligibility is determined by Lola's licensed provider.

Note: After submitting your registration, you will receive a payment link. To help us confirm your spot and prepare for your visit, please complete payment before attending the event. Same-day or on-site payments may be subject to additional charges.

Event Selection

Select the event you plan to attend.

Event *

Client Information

Tell us how to contact you and prepare for your visit.

First Name *

Last Name *

Phone *

Email *

Address

City

State

Zip Code

Age *

Injection Selection

Select Your Preferred Cocktail. NOTE: Pick any 3 for a flat fee of $60.

Final service eligibility is determined by a licensed provider. Please select any that apply.

Amino Blend - $30 B-12 - $30 L-Carnitine - $30 Lipo Mino - $30

Optional: choose up to 4 preferred injections. The $60 flat fee applies only when 3 are selected.

Health Screening

This screening helps our clinical team determine whether services may be appropriate.

Final service eligibility is determined by a licensed provider. Please select any that apply.

Pregnant Heart Disease Leber's Disease High Blood Pressure Currently receiving chemotherapy Warfarin or blood thinner prescription Other None of the above

Referral & Communication

Help us understand how you found us and how we may follow up.

Where did you learn about this event? *

Acknowledgment

Please review and accept before submitting.

By checking the box below, I confirm that the information I provided is accurate to the best of my knowledge. I understand that services from Lola's TruBalance & Wellness are subject to provider review and may not be appropriate for everyone. I understand that wellness services are not guaranteed to diagnose, treat, cure, or prevent disease, and I agree to ask questions before receiving any service.