DripsyFIT | Follow-Up

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Please Provide Your Height & Current Weight*
Which medication are you taking?*

SemaglutideTirzepatide
Are you experiencing appetite suppression?
Are you experiencing any side effects?*

NoneMild NauseaConstipationDiarrheaHeadacheFatigueOther
If side effects, are they manageable?*

YesNoN/A, I have none
Have there been any changes in your medical history since last refill?*

YesNo
Please explain any changes to your medical history.*
What would you like to do?*

Stay at current doseIncrease my dose (if eligible)Decrease my dose
Any additional comments or concerns you would like to share with Dripsy?
How would you like to receive your medication & supply refill?*

Pick up at Dripsy IV Bar - AlexandriaPick up at Dripsy IV Bar - LafayettePick up at Dripsy IV Bar - OllaShip to the address provided (Please note the cost of shipping $25 will be added to your checkout)
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)
I confirm that I am not pregnant, trying to become pregnant, or breastfeeding. I have not been diagnosed with medullary thyroid cancer or Multiple Endocrine Neoplasia type 2 (MEN2), and I have not experienced pancreatitis since my last medical approval. I verify that the information provided in this refill request is accurate and complete to the best of my knowledge. I understand that all refill requests are subject to medical review and approval, and that updated telehealth clearance may be required if my previous approval has expired.
Signature*
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