Semaglutide Client Registration

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Is this your first time using Semaglutide or Tirzepatide?

Are you entering this program through a business affiliate?

If yes, what is the name of the business?

Please select your preferred date and location for required labwork.

Labs will be ordered upon successful submission of your registration. You MUST complete your labs within 24 hours of date and time selected or your lab order will be automatically cancelled within the system.

Preferred Date and Time of Labs

Date

Hour MinutesAM/PM Option

Preferred LabCorp/Quest Diagnostics Location:

Appointment & Lab Fees

Please Note: Semaglutide should not be used in patients with a history of multiple endocrine neoplasia, medullary thyroid cancer, family history of medullary thyroid cancer, insulin-dependent diabetes, diabetes utilizing sulfonylureas or patients with history of low blood sugar (hypoglycemia). If you have any of the above, you will not be eligible to start Semaglutide and should not register for our program.

If you have had labwork within the last 60 days that is approved by our Medical Director, you may be eligible for a $100 credit toward your Semaglutide injections.

Submit your payment below:

Semaglutide Lab Fees

Required for all clients

$100.00 Quantity

Semaglutide Appointment Fee

Required for clients who are NOT currently using Semaglutide or Tirzepatide

$199.00

(Converting Clients ONLY) Semaglutide Appointment Fee

Select this option ONLY if you are currently receiving Semaglutide or Tirzepatide injections and are converting to our program from another location

$150.00 Quantity

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Semaglutide Client Registration

Submit your payment below:*

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