DripsyFIT Enrollment

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.

Name*

First NameLast Name

Date of Birth*

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.

Preferred Method of Contact*

Text MessagePhone CallEmail

Which Dripsy location is closest to you?*

This helps us assign your care to the correct provider.

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 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.

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

Once all your information is confirmed and your telehealth clearance is completed, we’ll send your invoice via text and email for easy payment.

How would you like to receive your medication?*

Pick up at Dripsy IV Bar - AlexandriaPick up at Dripsy IV Bar - LafayettePick up at Dripsy IV Bar - OllaShip to the address provided below (Additional $25)

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)

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.

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*