Weight & Metabolic Care — Financial Agreement
Review the billing terms for the GLP-1 program and sign to confirm your financial commitment.
Billing Terms I Agree To
I understand GLP-1 Support is an optional add-on, billed in addition to my existing membership.
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I acknowledge and agree
I understand the eligibility evaluation is included in my current membership — there is no cost to be assessed.
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I acknowledge and agree
I agree to the program fee of $75/month, beginning when treatment starts, through my efficacy checkpoint visit — then dropping to $50/month starting the billing cycle after that visit. The efficacy checkpoint is the video visit where my provider and I review whether treatment is working. It happens after about three months at my stable dose — and because reaching a stable dose typically takes 4–5 months, it usually falls around month 7–8 of treatment overall, not month 3.
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I acknowledge and agree
I understand video visits are included in the program fee, and in-person visits are available for an additional $50 per visit.
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I acknowledge and agree
I understand The Menopause Clinic prescribes only FDA-approved GLP-1 medications. We do not prescribe compounded GLP-1 products.
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I acknowledge and agree
I understand the medication itself is billed separately by the pharmacy and is not included in the program fee. Self-pay prices typically range from about $150 to $600 per month depending on the medication, dose, and program — and prices change. I will check the actual price of my specific medication and dose before filling my first prescription. Help finding my most affordable option is included in my program fee.
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I acknowledge and agree
I understand any labs are billed separately through standard lab billing.
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I acknowledge and agree
I understand billing begins only after my eligibility is confirmed, both my clinical consent and this financial agreement are signed, and treatment starts.
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I acknowledge and agree
I may discontinue the add-on at any time by notifying the clinic in writing (a portal message is fine) at least 10 days before my next billing date; with less notice, the next month's payment will still process. Payments already made are non-refundable. I understand that when the add-on ends, GLP-1 prescribing and refills through The Menopause Clinic end with it, because this medication requires active monitoring.
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I acknowledge and agree
Preferred format for your initial treatment visit
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Video (included)
In-person (+$50)
Full Name
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First Name
Last Name
Email
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example@example.com
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
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Agree & Submit
Agree & Submit
Should be Empty: