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Wellness Shop Order Form
All order placements are pending review by our medical professionals. All orders placed are patient specific. Please allow up to 21 days for order review by a medical professional, pharmacy ordering, and delivery from the pharmacy. If you have not received your order after 21 days, then please contact CWNC. We appreciate your cooperation and patience!
I am aware that I must reside in NC to place any orders with the Wellness Shop currently.
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Yes
I am aware that Coastal Wellness NC has the right to refuse completion of my Wellness Shop order based upon their assessment of my wellness form answers if there are any medical concerns and/or contraindications. I am also aware that should this occur, a refund will be issued to me.
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Yes
First Time weight management clients will select and pay for a telemedicine appointment at the bottom of this form if ordering Tirzepatide or Semaglutide weight management medications:
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Yes, please contact me for an appointment
N/A - Other item being ordered
N/A - I am re-ordering medications
N/A - I have already completed my telemedicine consult
If you are interested in a consultation with our health coach, David, please select the appropriate response below:
Yes, please contact me for an appointment
N/A
Name
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First Name
Last Name
Shipping Address: Can NOT be a P.O. Box
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
-
Day
Year
Phone Number
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Please enter a valid phone number.
Email
*
Did anyone from CWNC help to answer your questions and/or help you place order?
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Patient Medical Questionaire
Gender
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Male
Female
Height and Weight
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How active are you?
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Not Active
Somewhat Active
Moderately Active
Very Active
Height
*
Please list ALL allergies to medications or supplements:
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Please list ALL current medications or supplements:
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IF RE-ORDERING WEIGHT MANAGEMENT MEDICATIONS please list your medication name and CURRENT dose you are taking:
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Please select all applicable past or present medical conditions, if any:
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Diabetic Retinopathy
Thyroid Cancer
Gallbladder Disease
Acute Inflammation of Pancreas
Decreased Kidney Function
Multiple Endocrine Neoplasia Type 2
Family History of Medullary Thyroid Carcinoma
Kidney Disease with Likely Reduced Kidney Function
Allergy to Sulfa Medications
Hypoglycemia
Diabetes
Hypertension
Asthma
Low Potassium Level
Lebers Disease
None of the Above
Has anyone ever told you your kidneys or liver do not function properly?
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Yes
No
Please list any medical conditions NOT included above:
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Please list any surgical procedures you have had:
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Are you Pregnant or Breastfeeding?
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Yes
No
Not Applicable
I understand that Tirzepatide may disrupt oral contraceptive efficiency, and that I will need to use a barrier method for four weeks upon beginning and upon each dose escalation.
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Yes
No
Not Applicable
Do you have a primary care physician ?
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Yes
No
Primary Care Physician Name (if applicable):
I Understand that Coastal Wellness NC does NOT replace the routine care of a Primary Physician:
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Yes
I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages.
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Yes
I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels and/or other diagnostic testing by my primary care physician, or other specialist.
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Yes
I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy.
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Yes
I certify this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I agree to the therapy described above. I have been educated on the benefits, risks, and possible adverse reactions associated with hormone replacement therapy.
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Yes
I agree all the above health information submitted on the questionnaire is complete and accurate.
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Yes
I have read and understood the terms of this agreement
*
Yes
Signature
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Telemedicine Visit
Consult with our NP to review your wellness shop form prior to placement of order. Also available to answer questions you may have before and during your weight management and wellness journeys. Submit this form with payment to be contacted for an appointment.
$
20.00
Health & Wellness Coaching
Consult with our health and wellness coach to not only discuss, but also help implement lifestyle changes to optimize the work you’re putting in to achieve your goals. Submit this form with payment to be contacted for an appointment.
$
20.00
Anti-Wrinkle Cream
GHK-Cu Copper Peptide / Argireline / Leuphasyl. This Botox mimic improves skin firmness, elasticity, and clarity. Reduce and prevent fine lines, depth of wrinkles, and improve the structure of aged skin.
$
110.00
Quantity
1
2
3
Semaglutide - 1 Vial (Initial 10 Week Program)
(FDA Approved) Revolutionary weight management medication that targets visceral fat and helps to control appetite while keeping you feeling full longer. Alcohol pads and syringes included.
$
500.00
Quantity
1
Semaglutide - 2 Vials
THIS IS ONLY FOR PEOPLE ALREADY ESTABLISHED ON THE SEMAGLUTIDE PROGRAM BEYOND THE INITIAL 6 WEEKS. Alcohol pads and syringes included
$
850.00
Quantity
1
2
Tirzepatide - 1 Vial (Initial 6 Week Program)
Revolutionary weight management medication that targets visceral fat and helps to control appetite while keeping you feeling full longer. Alcohol pads and syringes included.
$
399.00
Quantity
1
Tirzepatide - 2 Vials
THIS IS ONLY FOR PEOPLE ALREADY ESTABLISHED ON THE TIRZEPATIDE PROGRAM BEYOND THE INITIAL 6 WEEKS. Alcohol pads and syringes included.
$
750.00
Quantity
1
2
Amino Acid Blend Injections (30mL)
This "Energy Shot" of amino acids boosts energy, shreds fat, and assists in muscle recovery and oxygenation. Glutamine, Arginine, Carnitine, Leucine, Isoleucine, and Valine.
$
150.00
Quantity
1
2
Glutathione Injections (30mL)
Your body's natural detox and antioxidant agent. Clears skin imperfections. Say goodbye to free radicals and toxins and enjoy its anti-aging properties!
$
150.00
Quantity
1
2
MICC Injections (30mL)
Boost metabolism, energy and weight loss with this blend of Methionine, Inositol, Choline, and Cyanocobalamin.
$
250.00
Quantity
1
2
Vitamin D Injections (5mL)
Anti-inflammatory, antioxidant, and neuroprotective properties support immune health, muscle function, and brain cell activity.
$
120.00
Quantity
1
NAD Injection
Don’t have time for a long infusion? Boost cognitive function, athletic performance and reverse the clock with NAD injections!
$
225.00
Quantity
1
2
NAD Nasal Spray
Don’t have time for a long infusion? Boost cognitive function, athletic performance and reverse the clock with NAD nasal spray!
$
215.00
Quantity
1
2
BPC157 Healing Peptide
Injection blend of 15 amino acids that accelerates the healing of different ailments, such as joint pain, tendon and ligament recovery, and skin wounds. Great for sports related and/or post operation wounds.
$
299.00
Quantity
1
2
CJC Ipamorelin - 8 week program
Peptide compound that stimulates the growth area of the brain responsible for muscle development, weight loss, and cognitive focus. Also known as the “fountain of youth” for its anti-aging properties. Includes syringes and alcohol pads for administration.
$
500.00
Quantity
1
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