Weight Loss Shot RequestComplete the form below to start the process. Name * First Name Last Name Date of Birth * Email * Cell Phone Number * (###) ### #### I agree to receiving notifications via text when my supplies are ready for pickup. It usually takes about a week for the pharmacy to process and fulfill my order. * Agree What vial are you interested in? * Semaglutide 1 mg Vial Semaglutide 2 mg Vial Semaglutide 5 mg Vial Tirzepatide 20 mg Vial Tirzepatide 40 mg Vial Tirzepatide 60 mg Vial Do you have history of pancreatitis? (if yes, you are not a candidate for semaglutide/tirzepatide) * Yes No Do you have active gallbladder problems such as gallstones? (if yes, you are not a candidate for semaglutide/tirzepatide) * Yes No Do you or your immediate family (mom/dad) have a history of thyroid cancer? (if yes, you are not a candidate for semaglutide/tirzepatide) * Yes No Are you pregnant or planning to become pregnant in the next two months? (Discontinue immediately if pregnancy occurs while on this medication as it can increase risk of birth defects) * Yes No Questions/Comments (optional) Legal Stuff: Client Privacy Rights. Terms and Conditions: https://docs.google.com/document/d/1lXGSUu3HkHxTQ57BZ5U60n-HWUFEMQhUf4xCT4nJSD8/edit?usp=sharing * I have read and agree to the terms above THANK YOU FOR YOUR ORDER! You are all set!We'll send you a text message as soon as your supplies are ready for pickup which typically takes about a week. During pick up, we'll provide you with all the necessary information. We’ll collect payment (Cash or Card) at the time of pickup. Pick up opportuties typically are a 3-6 pm widow most weekdays and occasionally on weekends. Client Privacy Rights. Terms and Conditions
