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.