DripsyFIT | Kickstart Quiz

Name*

First NameLast Name

Date*

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Please Provide Your Height & Current Weight

Upload a Picture of Your Scale Reading*

Which medication are you interested in taking?*

SemaglutideTirzepatide

Which program are you interested in?*

DripsyFIT (GLP-1/B6 Compound)DripsyFIT Remix (GLP-1/NAD+ Compound)

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 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.

💳 How would you like to pay for your weight loss plan?*

Month to MonthMembership6 Month Pack

How would you like to receive your medication & supplies?*

Pick up at Dripsy IV Bar - AlexandriaPick up at Dripsy IV Bar - LafayetteShip to the address provided (Must add $35 to check out in this form for iced overnight shipping)

Telemed Exam FeeA quick virtual consultation with a licensed healthcare provider to review your medical history and ensure DripsyFIT is safe and right for you. This exam is required for all new clients before starting your program. A $35 telehealth fee is required to complete your DripsyFIT exam. If approved, this fee will be applied toward your first month of medication. Note: The telehealth fee is non-refundable, regardless of approval, as it covers the cost of consultation with a licensed healthcare provider.

$35.00

Ship to My HomeImportant Shipping Notice: Please only add this item to your cart if you prefer to have your medication and supplies shipped directly to your home. • Overnight shipping is required and your package will be shipped on ice for safety. • Please allow 3–5 business days for pharmacy processing, which does not include shipping time.

$35.00

Total

$0.00

If shipping, please provide your shipping address if different than listed above. (Please note that you may receive 2 packages, one with your medication and one with your supplies)

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.

Signature*