DripsyFIT | Check-In Quiz

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.

Please Provide Your Height & Current Weight*

Which medication are you taking?*

SemaglutideTirzepatide

Which Program?*

DripsyFITDripsyFIT Remix (with NAD+)

Would you like to upgrade to our DripsyFIT Remix program that compounds your GLP-1 with NAD+ for added energy and weight loss support?*

YesNot this time

Number of Units Currently Taking*

Do you feel that you need to increase your dose?*

YesNo, stay the same this month

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 - LafayetteShip to the address provided (Please add the cost of shipping to your checkout below)

Want your medication shipped?

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 with 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*

DripsyFIT Refill Request