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  • 2025 Weight Loss Form

    2025 Weight Loss Form

    GLP1 / GIP / Lipo B/C | ALL OPTIONS |
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    BIG SAVINGS WITH A 3 MONTH SUPPLY OF SEMAGLUTIDE OR TIRZEPATIDE
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    Semaglutide [Compounded] [ ANY DOSE ]  Product Image
    Semaglutide [Compounded] [ ANY DOSE ] GLP-1 | Once weekly injection | Up to 15% weight loss |
    $399.00
      
    Tirzepatide [Compounded]  (Up to 7.5mg dose) [ STARTER DOSES ] Product Image
    Tirzepatide [Compounded] (Up to 7.5mg dose) [ STARTER DOSES ]GLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss |
    $499.00
      
    Tirzepatide [Compounded]  (10mg or 12mg) [HIGH DOSES] Product Image
    Tirzepatide [Compounded] (10mg or 12mg) [HIGH DOSES]GLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss |
    $550.00
      
    Tirzepatide [Compounded]  (15MG) [ MAX DOSE ]  Product Image
    Tirzepatide [Compounded] (15MG) [ MAX DOSE ] GLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss |
    $599.00
      
    Ozempic BRAND Product Image
    Ozempic BRANDGLP-1 | Once weekly injection | Up to 15% weight loss |
    $950.00
      
    Wegovy BRAND Product Image
    Wegovy BRANDGLP-1 | Once weekly injection | Up to 15% weight loss |
    $1,300.00
      
    Mounjaro BRAND Product Image
    Mounjaro BRANDGLP-1 + GIP - Once weekly injection | Up to 22.9% weight loss |
    $1,050.00
      
    Zepbound BRAND Product Image
    Zepbound BRANDGLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss |
    $1,050.00
      
    Lipo  (Addon) Product Image
    Lipo (Addon)Contains methionine and choline, which support fat metabolism by aiding liver function and the breakdown of stored fat. This can help enhance weight loss, improve energy levels, and support liver health when combined with a proper diet and exercise regimen.
    $45.00
      
    Lipo-B (Addon) Product Image
    Lipo-B (Addon)Contains methionine and choline to support fat metabolism and liver function, plus cyanocobalamin (Vitamin B12) to boost energy production and red blood cell formation. This combination helps enhance fat breakdown, improve energy levels, and support overall metabolic function when used alongside a healthy diet and exercise.
    $55.00
      
    Lipo-C (Addon)  Product Image
    Lipo-C (Addon) Contains methionine and choline to support fat metabolism and liver function, similar to Lipo and Lipo-B, with the added benefit of carnitine to enhance fat burning and energy production. In addition, it includes dexpanthenol (Vitamin B5), which supports cellular metabolism and helps convert fats and carbohydrates into energy more efficiently.
    $65.00
      
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