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.