Dr. V Health Appointment Form

Appointment Form

Please fill out this form to schedule your appointment for the weight loss program.
Full Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Height (inches)*
Email Address*
example@example.com
Current Weight (lbs)*
Target Weight (lbs)*
Have you or any of your family members ever been diagnosed with thyroid cancer(including medullary thyroid carcinoma) or Personal Hx of acute pancreatitis?*
Are you pregnant or breastfeeding?*
Peptide Pricing (Medication Only)

Semaglutide: $159.99
Tirzepatide: $339.99
NAD+: $159.99
Glutathione: $59.99
Sermorelin: $159.99

⚠️ Important: These prices are for the medication only. An active membership (Wellness or Premium) or a Pay-Per-Consult is required in addition to the cost of medication. Membership or consultation fee must be selected and paid at the time of scheduling.
Subscriptions*

Wellness Membership $39.99Premium Membership $69.99Pay Per Consult $79.99
Preferred Appointment Date and Time*
Should be Empty: