*At this time we are not taking patients located in:

*CALIFORNIA and HAWAII

Delivery to the following states requires additional charges for shipping and processing:

ALABAMA

ARKANSAS

KANSAS

MICHIGAN

MINNESOTA

MISSISSIPPI

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List your current medications (if currently on no medications please put N/A)

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What professionals are saying about Tirzepatide?By checking this box I watched the video above and fully understand the material.

What professionals are saying about Semaglutide?By checking this box I watched the video above and fully understand the material.

How to draw up and give yourself a subcutaneous injection?By checking this box I watched the video above and fully understand the material.

I agree to the I understand that someone will contact me within the next 72 hours to inform me if I am a candidate for the weight loss program - with the exception of weekends. I will be notified 72 hours from the first business day after the weekend. I will not complete the payment process until approved, failure to make a payment without approval will result in a processing fee if deemed not a candidate & conditions. Yes, I understand.

By my signature below I do willingly request and consent to weight loss products delivered from a compound pharmacy. I understand that there is no warrant or guarantee of results due largely to off-site administration and patient-controlled application. I acknowledge that all statements provided on these forms, and the Confidential Health History Forms are true and accurate to the best of my knowledge and that my treatments will be based on the information provided herein and if I willingly withhold information, I accept full liability for any consequence that may arise therefrom.View terms of use

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