Wellness Shop Order

Wellness Shop Order Form

All Order Placement Pending Review of Wellness Shop Intake Form By Medical Professionals. Placed Are Patient Specific, Please Allow Up Three Weeks Until Delivery Due to Processing Times. First Time Patients Must Select “Initial Tele-Health Visit”
Name*

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Date of Birth*

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Date
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example@example.com
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Demographics
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African AmericanCaucasianPacific IslanderAmerican Indian or Alaskan Native
Hispanic or Latino?

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Gender*

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Patient Medical History
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Weight*
Please List Allergies to Medications or Supplements *
Please list all past medical history or surgeries*
Do you have a history of heart disease?

YesNo
Please List All Current Medications*
Please select all applicable past or present medical conditions, if any*

Diabetic retinopathyThyroid CancerDisease of the gallbladderAcute inflammation of the pancreas.Decreased kidney functionMultiple endocrine neoplasia type 2.Family history of medullary thyroid carcinomaKidney disease with likely reduction in kidney functionAllergies to sulfa medicationsHypoglycemiaDiabetesHypertensionAsthmaLow Potassium LevelLebers DiseaseNone of the above
Has anyone ever told you your kidneys or liver do not function properly?*

YesNo
Are you Pregnant or Breastfeeding?*

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Do you have a primary care physician ?*
Social History
Do You Smoke?

YesNo
How active are you?*

Not activeSomewhat activeVery active
I understand that tirzepatide may disrupt oral contraceptive efficiency, and that I will need to use a barrier method for four weeks upon beginning and upon each dose escalation.*

YesNo
I Consent to Creation of Patient Portal*

YesNo
I Understand that Coastal Wellness is Telemedicine Clinic Does not Replace the Routine Care of a Primary Physician*

YesNo
What are your wellness goals?
Are you currently on semaglutide (ozempic), tirzepide (mounjaro)?

YesNo
I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages. I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels or other diagnostic testing by my primary care physician, or other specialist. I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I understand the risk associated with thyroid cancer and peptide weight loss injections. I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy. I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as to not being treated. Those risks and potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of and other hormone treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefit from the administration of hormone therapy. I certify this form has been fully explained to me, that I have read it or have had it read to me and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I agree to the therapy described above. I have been educated on the benefits, risks, and possible adverse reactions associated with hormone replacement therapy. I agree all the above health information submitted on the questionnaire is complete and accurate.
I have read and understood the terms of this agreement *

Yes
Signature*

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Are You Using A Payment Plan? (Must Be Pre-Approved With Qualifying Amount)

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If Using Payment Plan, Please Enter In Requested Program Below, and Do Not Make Medication Selections or Provide Payment.
“Semaglutide 20 week, Tirzepatide 10 week, MIC B12 , etc”
Link To Payment Plan Application: pay.withcherry.com/coastalwellnessmobile.com

Programs

First Time Patient Telehealth Assessment Product Image

First Time Patient Telehealth Assessment 15 Minute Tele-Health Assessment For Initial Patients Only

$39.00 Quantity

Semaglutide 10 Week Program 2 Product Image

Semaglutide 10 Week Program 2Lose weight with a once-a-week injection of this FDA approved medication that targets the "appetite" portion of your brain. Decreases appetite and shreds visceral fat. 10 weeks from beginning dosage. Compounded with L-carnitine. 5.3 mg total.

$399.00 Quantity

Semaglutide 15 Week Program Product Image

Semaglutide 15 Week ProgramLose weight with a once-a-week injection of this FDA approved medication that targets the "appetite" portion of your brain. Decreases appetite and shreds visceral fat. 15 weeks from beginning dosage. Includes alcohol wipes, syringes and shipping. Compounded with L-carnitine. 10.6 mg total

$549.00 Quantity

Semaglutide 20 Week Program Product Image

Semaglutide 20 Week ProgramLose weight with a once-a-week injection of this FDA approved medication that targets the "appetite" portion of your brain. Decreases appetite and shreds visceral fat. 10 weeks from beginning dosage. Compounded with L-carnitine. 15.9 mg total.

$799.00 Quantity

Tirzepatide 6 Week Program Product Image

Tirzepatide 6 Week Program Generic form of Mounjaro, the Revolutionary Weight Loss Peptide. Alcohol and Syringes Included. 6 Weeks Of Injections from Intial Dosage. Compounded with B12. 20 mg total.

$399.00 Quantity

Tirzepatide 10 Week Program Product Image

Tirzepatide 10 Week ProgramTirzepatide, generic form of mounjaro includes a 10 week program from initial dosage. Includes alcohol wipes, syringes and shipping. Compounded with B12. 40mg total.

$799.00 Quantity

Tirzepatide 17 Week Program Product Image

Tirzepatide 17 Week Program Tirzepatide, generic form of mounjaro includes a 10 week program from initial dosage. Includes alcohol wipes, syringes and shipping. Compounded with B12. 60 mg total.

$1,199.00 Quantity

Weight Loss Booster Injections Product Image

Weight Loss Booster Injections Boost Your Peptide Injection Progress with Injections of MIC B12 and GACLIV, a blend of 6 different amino acids to boost energy, weight loss and fat reduction. Methionine inositol choline (MIC) B12 injections contain a blend of nutrients that help your body release fatty deposits. For example, inositol stimulates fat removal by your liver, while choline prevents cholesterol buildup and deposits. Methionine, an essential amino acid, helps inositol and choline work even more efficiently. MIC injections also contain vitamin B12, which can further stimulate your metabolism and give you a boost of energy, especially if you don’t get enough B12 each day. When methionine, inositol, choline, and B12 are combined into one injection, you have a higher chance of getting rid of excess fatty deposits throughout your body.

$399.00 Quantity

BP157 Healing Peptide 2mg/ml 7.5 ml Product Image

BP157 Healing Peptide 2mg/ml 7.5 mlInjection blend of 15 amino acids that accelerates the healing of different ailments such as joint pain, tendon and ligament recovery, and skin wounds. Great for sports related and/or post operation wounds.

$299.00 Quantity

Glutathione 200mg/ml 30mlYour body's natural detox and antioxidant. Clears skin imperfections, Say goodbye to free radicals, and toxin and enjoy its anti-aging properties!

$150.00 Quantity

NAD Injections 200mg/ml 5ml Product Image

NAD Injections 200mg/ml 5mlDon’t have time for a long infusion? Boost cognitive function , athletic performance and reverse the clock with NAD injections!

$225.00 Quantity

NAD Nasal Spray Don’t have time for a long infusion? Boost cognitive function , athletic performance and reverse the clock with NAD nasal sprays!

$215.00 Quantity

GACLIV Energy Amino Blend 30ml Product Image

GACLIV Energy Amino Blend 30ml Glutamine, Argenine, Carnitine, Leucine, Isoleucine, Valine= Glutamine is one of the body’s most abundant amino acids and is the building block for all essential proteins. It is used to boost the immune system and combat the effects stress on the body. It enhances exercise performance and speeds up muscle recovery which allows you to burn more calories. Arginine is an amino acid that converts into nitric oxide. Nitric oxide improves circulation and blood flow. Its positive effects on blood circulation improve workout performance and reduce muscle recovery. Carnitine simply put, converts body fat into energy. It reduces body fat, increases muscle mass, improves stamina, improves strength and lessens fatigue. Its muscle building properties are pretty impressive which also makes it an excellent amino for fat burn too. Carnitine has also been used to boost energy during times of caloric deficit which can help to eliminate fatigue and irritability while dieting. Helps improve concentration and cognitive thinking. L-Leucine, L-Isoleucine, and L-Valine are branch chain amino acids. BCAA’s are roughly 1/3 of the amino acids with in muscle tissue. Essential amino acids are not synthesized by the body on their own. This is why supplementation is needed. These specific aminos promote muscle growth by protein synthesis. They also help prevent fatigue. L-Isoleucine: increases endurance, helps repair lean tissue, and promotes blood clotting at the site of injury.

$175.00 Quantity

Anti Wrinkle Cream GHK-Cu copper peptide / Argireline / Leuphasyl. This botox mimic improves skin firmness, elasticity, and clarity. Reduce fine lines, depth of wrinkles, and improve the structure of aged skin.

$199.00 Quantity

CJC/Ipamorelin 12 Week 12mg/24mg Product Image

CJC/Ipamorelin 12 Week 12mg/24mg Peptide compound that stimulates the growth area of the brain responsible for muscle development, weight loss, and cognitive focus. Also known as the “fountain of youth” for its anti aging properties.

$759.00 Quantity

CJC Ipamorelin 6 Week 6mg/12mg in 6ml Product Image

CJC Ipamorelin 6 Week 6mg/12mg in 6mlPeptide compound that stimulates the growth area of the brain responsible for muscle development, weight loss, and cognitive focus. Also known as the “fountain of youth” for its anti aging properties.

$375.00 Quantity

Anti Aging Power DuoFight aging with two power house injections of NAD an Glutathione.

$279.00 Quantity

Vitamin D Injections 100,000iu/ml 5ml Product Image

Vitamin D Injections 100,000iu/ml 5mlFight deficiencies and obtain ultimate supplement absorption with vitamin d3 injections

$150.00 Quantity

MIC B12 Injections 25mg/50mg/50mg/2mg in 30ml Product Image

MIC B12 Injections 25mg/50mg/50mg/2mg in 30ml What are MIC B12 Injections?Methionine inositol choline (MIC) B12 injections contain a blend of nutrients that help your body release fatty deposits. For example, inositol stimulates fat removal by your liver, while choline prevents cholesterol buildup and deposits. Methionine, an essential amino acid, helps inositol and choline work even more efficiently.MIC injections also contain vitamin B12, which can further stimulate your metabolism and give you a boost of energy, especially if you don’t get enough B12 each day. When methionine, inositol, choline, and B12 are combined into one injection, you have a higher chance of getting rid of excess fatty deposits throughout your body.

$199.00 Quantity

Tri-Immune BoosterZinc, Glutathione and Vitamin C in One Simple Injection.

$199.00 Quantity

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Wellness Shop Order Form

Demographics

Patient Medical History

Social History

Payment Methods