You can always press Enter⏎ to continue
DripsyFIT | Enroll

DripsyFIT | Enroll

Hi there, please fill out and submit this form.
19Questions

HIPAA

Compliance

  • 1

    Important Information About DripsyFIT Enrollment

    Please note that this intake form and booking are for enrollment and record-keeping purposes only as required by our partner pharmacy. You DO NOT need to physically come to a Dripsy IV Bar location at the appointment time shown.

    During your enrollment process, you may be asked to place a card on file for membership processing only.

    If you are paying month-to-month, an invoice will be sent to you via text and email once your plan has been reviewed and approved.

    No medication will be ordered from our partner pharmacy until payment has been received.

    Our team will contact you via your preferred communication method if additional details or telehealth steps are needed. When your medication is ready, you'll receive pickup or delivery instructions.

    By proceeding, you acknowledge that you have read and understand these terms and that your appointment time serves only to initiate your enrollment it is not an in-person visit.

    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Date of Birth
    -
    Pick a Date
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Please Select
    • Please Select
    • Alexandria
    • Lafayette
    • Olla
    • Lake Charles
    • Outside of Louisiana
    Press
    Enter
  • 9
    Note: BMI must be 27 or greater to qualify for Semaglutide or Tirzepatide
    Press
    Enter
  • 10
    Press
    Enter
  • 11
    Press
    Enter
  • 12
    Press
    Enter
  • 13

    PAYMENT OPTIONS
    Choose the option that works best for you. Each includes your GLP-1 prescription (semaglutide or tirzepatide), plus extra perks depending on your selection.

    Month-to-Month Plan

    Flexible monthly payments based on your current dose. Price increases as your dose increases. No long-term commitment.

    DripsyFIT or DripsyFIT Remix Membership
    ⭐ Best value & perks!

    $275/month for Semaglutide/B6 or $375/month for Semaglutide/NAD+
    $400/month for Tirzepatide/B6 or $500/month for Tirzepatide/NAD+
    Includes:
    ✓ Weekly Skinny or Skinny+ Shot
    ✓ Member pricing on all other services

    *Requires at least 3 month comitment before canceling membership.

    6-Pack (Pay Now or Use Affirm)
    Prepay for 6 months of treatments.

    $1600 for Semaglutide/B6 or $2200 for Semaglutide/NAD+

    $2500 for Tirzepatide/B6 or $3100 for Tirzepatide/B6

    *Includes your monthly GLP-1 dose no matter the dose you are prescribed
    You can use Affirm to split payments over time.

    Press
    Enter
  • 14
    Please Select
    • Please Select
    • Month to Month
    • DripsyFIT Membership
    • 6 Month Package
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • 17

    Telehealth Exam Requirement

    A telehealth exam with a licensed healthcare provider is required prior to starting any weight loss medication. This evaluation ensures that treatment is safe and appropriate for you based on your medical history and current health status.

    Once completed, your telehealth exam approval is valid for up to six (6) months, unless you experience a significant change in your medical history (such as a new diagnosis, medication, or health event).

    You can complete your telehealth exam at the following link:
    www.getdripsy.com/clear. You will also be redirected to the Dripsy CLEAR portal at the end of this form and a copy will be sent to your email.

    Please note that there is a $35 telehealth fee, paid up front through our telehealth portal.

    -This fee is non-refundable, as it covers the cost of the providers time and evaluation regardless of whether you are approved for treatment.

    -Your first month's medication cost will reflect a $35 discount to offset this initial expenditure.

    This telehealth exam covers all services offered by Dripsy IV Bar and may be used for any future IV therapy, injection, peptide, or wellness service during its six-month validity period.

    By continuing, you acknowledge that you understand and agree to the terms of the required telehealth evaluation.

    Press
    Enter
  • 18

    Medications and Consent
    Please read the following information carefully and provide your consent for participation in the DripsyFIT Weight Loss Program, including the use of Semaglutide and Tirzepatide, compounded with either Vitamin B6 or NAD+.

    Medications

    Semaglutide (B6 or NAD+ compound) – Mimics the GLP-1 hormone to help regulate appetite, improve blood sugar, and support weight loss.

    • Potential Benefits: Reduced appetite, improved blood sugar control, significant weight loss, enhanced energy (NAD+ compound)
    • Potential Side Effects: Nausea, vomiting, diarrhea, abdominal discomfort

    Tirzepatide (B6 or NAD+ compound) – Dual GIP and GLP-1 receptor agonist that supports weight loss and metabolic health.

    • Potential Benefits: Enhanced weight loss, appetite suppression, improved blood sugar, increased energy (NAD+ compound)
    • Potential Side Effects: Nausea, vomiting, diarrhea, constipation

    Consent and Agreement
    By signing below, you acknowledge that you have read and understood the information provided about the DripsyFIT Weight Loss Program and the medications involved. You consent to participate in the program and agree to the use of Semaglutide and Tirzepatide, including their B6 or NAD+ compounded forms. You also understand the potential benefits and risks of these medications.

    Press
    Enter
  • 19
    Medications and Consent: Please read the following information carefully and provide your consent for participation in the DripsyFit Weight Loss Program, including the use of the following medications: Sermorelin, Semaglutide, and Tirzepatide. Sermorelin: Sermorelin is a growth hormone-releasing hormone (GHRH) used to stimulate the production of growth hormone in the body. Potential Benefits: Increased energy, improved metabolism, and enhanced weight loss. Potential Side Effects: Headache, flushing, dizziness, and injection site reactions. Semaglutide: Semaglutide is a medication used to improve blood sugar control and support weight loss by mimicking the effects of the hormone GLP-1. Potential Benefits: Reduced appetite, improved blood sugar levels, and significant weight loss. Potential Side Effects: Nausea, vomiting, diarrhea, and abdominal pain. Tirzepatide: Tirzepatide is a dual GIP and GLP-1 receptor agonist used to support weight loss and improve blood sugar control. Potential Benefits: Enhanced weight loss, improved blood sugar levels, and reduced appetite. Potential Side Effects: Nausea, vomiting, diarrhea, and constipation. Consent and Agreement: By signing below, you acknowledge that you have read and understood the information provided about the DripsyFit Weight Loss Program and the medications involved. You consent to participate in the program and agree to the use of Sermorelin, Semaglutide, and Tirzepatide as part of your weight loss journey. You also understand the potential benefits and side effects of these medications.
    Powered by Jotform SignClear
    Press
    Enter
  • Should be Empty:
Question Label
1 of 19See AllGo Back
close