Harmony HRT Metabolic Reset Package Form

PACKAGES AND PRICE LIST


HARMONY LITE	HARMONY COMPLETE	HARMONY ELITE

(Labs not included)

$299 MONTH*

$399 MONTH*

$499 MONTH*

* 2 month comittment required for all packages. Payment set up via auto pay with a 30 day notice of cancellation required.

^Semaglutide .5mg per dose standard in package. Dosages greater than .5mg, Tirzepatide or oral options avaiable for an additional fee.
Harmony LiteHarmony CompleteHarmony Elite
Patient Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Information for Patient
Weight*
Height*
InjectionOral (Additional Cost per month)
Semaglutide (Standard)Tirzepatide (Additional Cost)Discuss with Provider which is the best option
Should be Empty: