Consult Request @ Infusalounge Wellness Spa

Thank you for choosing InfusaLounge for your weight loss solution!

You can initiate a refill each month at your own pace!

We are licensed in TX, CO, TN, KS, NM & FL

Refer 3 Friends and receive $200 your next Refill!

Join our FB Group and share your progress! You could win a $50 gift card to Lululemon, Amazon or More!

InfusaLounge Wellness Semaglutide & Tirzepatide Support Group!

It is simple to get started and schedule your consultation with our provider.

1. Complete the health questionnaire.

2. Take a picture of your driver's license and upload it.

3. Take a picture of yourself (this is for your protection) and upload it.

4. Pick a date and time of day you would like the practitioner to call you.

When you submit the form, your card will be charged for the script and Consultation.

We suggest a minimum of 3 Mo for up to 20lbs +

We have a discount on Step Therapy since multiple vials are shipped in one shipment.

After submitting your information, please complete the payment details.

*Please Note: If your submission is not approved by the provider, we will refund your payment within 48-72 hrs!

** WE DO ACCEPT CareCredit, HSA & FSA CARDS**

For CarecCredit transactions, please call the spa at

972-546-4318

All syringes and needles are included in the program.

The medical provider will attempt to call 2 times. If you want to change the date or time, please email us at: scheduling@infusalounge.com

We are excited to see your results!

Please note the address you enter will be where your medication is shipped.

We will only ship after the consultation and payment has been received. You should receive your medication within two days.

Full Name*

Gender*

Phone Number*

Area CodePhone Number

Date of Birth*

DayMonthYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail Address*

Consult Request Date*

Date

Best time to contact you*

Primary Care Physician

Provider will not be contacted

Lets Calculate your BMI:

How Often Do you Exercise?

Have you tried other Medications for Weight Loss? If so which Medications?

Any Medical History our Provider should know during the consult?

Hormone Medications?

Problems with Sleep?

YesNoOther

Do you suffer from Anxiety or Depression?

YesNoOther

Have you been Diagnosed with Thyroid Isssus?

YesNoOther

Do you Suffer from Headaches?

YesNoOther

Do you Suffer from Chronic Pain?

YesNoOther

Please List all Current Medications:

Would you like Zofran called in to your local pharmacy, for nausea?

YesNo

If Yes, Please enter the Pharmacy and cross streets

Semaglutide & Tirzepatide is contraindicated in patients with a personal or family history of certain types of thyroid cancer, specifically thyroid C-cell tumors such as medullary thyroid carcinoma (MTC), or in patients with multiple endocrine neoplasia syndrome types.

Take Photo of yourself - this is for verification of identity*

Take a Photo of your Drivers License*

TELEMEDICINE PATIENT CONSENT PURPOSE: The "Telemedicine Consent Form" aims to get the patient's consent to participate in telemedicine appointments with the provider. RECORDS: Telecommunications with patients will not be recorded and stored. Patient's medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

TELEMEDICINE INFORMATION: The medical information related to the patient's history, records, and tests will be discussed during the telemedicine appointment with video and audio. ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask questions related to telemedicine appointments and technical requirements for telecommunication.

By signing this form, I understand that all the laws that protect my privacy of medical history or information are also applied to telemedicine practices. I understand that I can withdraw the consent at any time, which will not affect my future treatment procedures. I understand that I can be charged additional fees that my insurance does not cover. I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis. ** All Sales are Final - No Refunds will be processed unless you are not a candidate for the therapy.** The Pharmacy will not take the Medication back.

I agree to release InfusaLounge Wellness Spa LLC, its employees or contractors from all liability, with previously used Semaglutide/Tirzepatide adverse affects, that were not prescribed by InfusaLounge Wellness Spa, LLC and/or current Semaglutide/Tirzepatide prescriptions ordered by InfusaLounge Wellness Spa, LLC. All Medical History know or not know that is not disclosed to the provider at the time of consultation. All changes in medical history must be reported to the provider on the monthly progress refill form. There are no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned medication.

Signature*

Time

:HourMinutesAM/PM Option

How did you hear about InfusaLounge Wellness Spa?

Referred By a Friend? Enter Their Name Below.

My Products

Semaglutide

3 Mo Step Therapy Semaglutide$740.00

You will receive 3 Vials Mo 1 - 0.25mg, Mo 2 - 0.50mg, and Mo 3 - 1.0mg - Includes Provider Consult Fee, & Supplies

Semaglutide 0.25mg$160.00

Starting Does 0.25mg

Semaglutide 0.50mg$235.00

Stay on/Increase 0.50mg

Semaglutide 1mg$275.00

Stay on/Increase 1mg

Semaglutide 1.7mg$300.00

Stay on/Increase 1.7mg

Semaglutide 2.4mg$325.00

Stay on/Increase 2.4mg

Tirzepatide

3 Mo Step Therapy Tirzepatide$1,140.00

Tirzepatide 2.5mg - 5mg - 7.5mg Includes Provider Consult Fee, and Supplies

Tirzepatide 2.5mg$330.00

Starting Dose 2.5 mg

Tirzepatide 5mg$430.00

Stay on/ Increase 5 mg

Tirzepatide 7.5mg$480.00

Stay on/ Increase 7.5 mg

Tirzepatide 10mg$530.00

Stay on/ Increase 10 mg

Tirzepatide 12.5mg$590.00

Stay on/ Increase 12.5 mg

Tirzepatide 15mg$630.00

Stay on/ Increase 15 mg

Weight Loss Booster's

Meal Plan's$30.00

Gluten-Free Recipes Pack High-Protein Recipes Pack 5-Ingredient Recipes Pack Vegan Recipes Pack Low-Carb Recipes Pack Vegetarian Recipes Pack Smoothie Recipes Pack Shopping Lists & Meal Planner Examples for ALL Recipes

MIC Lipo Injections - Methionine, Inositol, Choline, Vitamin C, B-1 -2-5-6, BCAA, Carnitine.$255.00

10 Week + supply - Intramuscular Injection into the muscle -- Methionine: Helps break down sugars & carbohydrates and convert to energy. Inositol: Converts food to energy and cuts insulin resistance Choline: Healthy nerve cells, cuts muscle recovery time, helps convert fat to energy. BCAA: Bring on muscle growth, Ease muscle soreness, Feel less exercise fatigue, Prevent muscle wasting Carnitine: Building block for proteins, helps body burn fat as fuel. Thiamine (B1): Improves immune system, helps convert fat and carbohydrates into energy. Riboflavin (B2): Increases metabolism, supports immune system. Preserves lean body tissue muscle. Improves liver detoxification. Improves mood and mental clarity. The injection is given every 5 to 10 days as needed into the muscle.

AOD-9604 CREAM$299.00

The AOD-9604 works by increasing metabolism while speeding up the fat-burning process. Support reduction of body fat. Regulation of fat metabolism, Stimulates lipolysis, and Inhibits lipogenesis

NAD+ At Home Therapy$287.00

10 Week Supply - The main benefits of NAD+ injections at 100mg/mL include: Enhanced cellular energy production Improved cognitive function and mental clarity Potential anti-aging effects Support for DNA repair and cellular health Increased metabolism and weight management Improved athletic performance and recovery Potential neuroprotective effects Reduced inflammation and oxidative stress This injection offers rapid absorption for maximum therapeutic benefits across various bodily functions.

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All Pricing - Includes Provider Consult Fee, & Supplies