DripsyFIT | Follow-Up

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Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.Date of Birth
Date
Month
Day
Year
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Which Dripsy location is closest to you?* This field is required.
Please Select
Please Select
Alexandria, LA
Lafayette, LA
Olla, LA
Lake Charles, LA
Outside of Louisiana
We’ll route your file to the contractor serving this region..
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Please Provide Your Height & Current Weight* This field is required.Note: BMI must be 27 or greater to qualify for Semaglutide or Tirzepatide
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Which medication are you taking?* This field is required.
Semaglutide
Tirzepatide
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Which Program?* This field is required.
DripsyFIT
DripsyFIT Remix (with NAD+)
9
Number of Units Currently Taking* This field is required.
10
Do you feel that you need to increase your dose?* This field is required.
Yes
No, stay the same this month
Decrease my dose
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Any additional comments or concerns you would like to share with Dripsy?
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Ok
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How would you like to receive your medication & supply refill?* This field is required.
Pick up at Dripsy IV Bar - Alexandria
Pick up at Dripsy IV Bar - Lafayette
Pick up at Dripsy IV Bar - Olla
Ship to the address provided (Please note the cost of shipping $25 will be added to your checkout)
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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)
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Ok
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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.
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Signature* This field is required.By proceeding, you acknowledge that no medication will be ordered from our partner pharmacy without an approved prescription from your telehealth exam with one of our licensed providers, and without payment made through our rewards app, in person, or by calling us at 337-349-1905 to request an invoice. Additionally, medications will not be shipped to your home unless the $20 shipping fee is paid during this form submission. *Please allow up to 24 hours for a link to sent connecting you with one of our healthcare providers your telehealth check-in. *
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