Vitality Health Refill Request Form

What is your First & Last Name?

What is your CURRENT weight?

What is your GOAL weight?

Are you having any side effects?

What is your current dosage in UNITS?

Would you like a virtual or in office appointment to discuss your weightloss plan?

Please select the option and then click the link for payment.

*If you have a recent referral I will provide you with a separate invoice to reflect your $25 discount*

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Semaglutide/b12/glycine 5 mg vial $339 https://buy.stripe.com/dR6eWD0lv0sM32UcMN

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Semaglutide/b12/glycine 10 mg vial $429 https://buy.stripe.com/eVa01J2tDgrK46YcMO

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Tirzeptide/b12/glycine 20 mg vial $365 https://buy.stripe.com/4gw8yf5FPdfybzq4gj

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Tirzeptide/b12/glycine 30 mg vial $465 https://buy.stripe.com/8wM01J6JTcbu9ri7sw

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Please select the option and then click the link for payment.

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MICC (Methionine/Inositol/Choline/Cyanocobalamin) 10 Week Supply $80

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NAD+ 200 mg/mL 2000mg(10ml) $199

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Semorelin 3mg $90

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Glutathione 200mg/ml 2000mg(10ml) $99

https://buy.stripe.com/4gw5m37NX5N6fPG5ku

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