Semaglutide Intake Form

Client Questionnaire/Assessment Tool

Consent for Weight Loss Treatment Using Semaglutide

Please Initial After Each Statement Below

INTRODUCTORY PRICE:

The DRIPBaR 8-week Starter Program is $600, with B12 Shots $760

(Dosing: 4 weeks at 1 unit / .25mg + 4 weeks at 2 units / .5mg)

The DRIPBaR offers packages beyond the 8-week starter program. Unit volume requires a quick approval from our medical provider.

- 4 weeks at 2 units / .5mg = $400

- 4 weeks at 4 units / 1.0mg = $600

- 4 weeks at 6 units / 1.5mg = $700

- 4 weeks at 8 units / 2.0 mg= $800

- 4 weeks at 10 units / 2/5,g = $1,000

  • Ask about our 16 week program for $2,000



MEMBERS SPECIAL: Receive complimentary blood draw for lab work and a B12 shot* for each week of your plan. *Members can substitute B12 for a B-complex

Required Blood Work

  • Comprehensive Metabolic Panel (CMP)

  • Lipid Panel

  • Blood work results must be within 90 days

  • The DRIPBaR New Tampa can assist with Labs. The Blood Draw fee is $80 and the Lab Fee is approximately $65 (Paid directly to the Lab).

By signing below, I certify that I have read and fully understand this consent form and understand the risks and benefits associated with my treatment for weight loss.  Please sign full name below.