Semaglutide & Tirzepatide

Intake Form

Client Questionnaire/Assessment Tool

Consent for Weight Loss Treatment Using Semaglutide or Tirzepatide

Please Initial After Each Statement Below

INTRODUCTORY PRICES FOR SEMAGLUTIDE and TIRZEPATIDE (subject to change):

MEDICAL DIRECTOR APPROVAL IS REQUIRED BEFORE STARTING OUR PROGRAMS

SEMAGLUTIDE:

The DRIPBaR 8-week Starter Program is $600

(Dosing: 4 weeks 0.25mg + 4 weeks at 0.5mg)

The DRIPBaR offers packages beyond the 8-week starter program. Unit volume requires a quick approval from our medical provider.

- 4 weeks at 0.25mg = $200

- 4 weeks at 0.5mg = $400

- 4 weeks at 1.0mg= $600

- 4 weeks at 1.5mg = $700

- 4 weeks at 2.0mg = $800

- 4 weeks at 2.5mg = $1,000

  • Ask about our 16 week program for $2,000

TIRZEPATIDE:

The DRIPBaR 8-week Starter Program is $900

(Dosing: 4 weeks 2.5mg + 4 weeks at 5.0mg)

The DRIPBaR offers packages beyond the 8-week starter program. Unit volume requires a quick approval from our medical provider.

- 4 weeks at 2.5mg = $400

- 4 weeks at 5.0mg = $600

- 4 weeks at 7.5mg= $750

- 4 weeks at 10.0mg = $900

- 4 weeks at 12.5mg = $1,050

- 4 weeks at 15.0mg = $1,200

  • Ask about our 16 week program for $2,800



MEMBERS SPECIAL: Receive complimentary blood draw for lab work and a B12 shot* for each week of your plan. *Members can substitute B12 for a B-complex

By signing below, I certify that I have read and fully understand this consent form and understand the risks and benefits associated with my treatment for weight loss.  Please sign full name below.