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.

How It Works

Complete this form and continue to telehealth for your clearance visit. If approved and prescribed, we will send you a payment link for your medication. Once payment is received, your order will be placed with our partner pharmacy. Pharmacy deliveries arrive every Wednesday for Alexandria and Lafayette, and every Thursday for Olla. Need it faster? Select shipping on your form or call 318-625-7090 for more information.

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.Format: (000) 000-0000.

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

Which medication are you interested in taking?*

SemaglutideTirzepatide

Are you transferring your program from another clinic?*

Yes (Please upload a photo of your current prescription below)No

Upload a photo of your current prescription if you are transferring to Dripsy from another clinic.

Are there any questions or concerns you would like to share with the Dripsy team?

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 Vitamin B6 .

Medications

Semaglutide– 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 (B6 compound)
- Potential Side Effects: Nausea, vomiting, diarrhea, abdominal discomfort
Tirzepatide– 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 (B6 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 compounded forms. You also understand the potential benefits and risks of these medications.

Signature*