Contact Us

Contact Us

Call to Order: 775-384-2189
Email: jacquelinew@intricatemindbody.org
Fax: (775) 384-2254

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First Name and Last Name *

First

Last

Address

City

State

Zipcode *

Date of birth

Sex Assigned at Birth *

• Female
• Male
• Prefer not to say

Email Address *

Phone

Weight

Height

Allergies

• No known drug allergies
• Penicillin
• Sulfa drugs
• Food allergies

Other Allergies

Current Medications

Chronic Conditions

• High blood pressure
• Diabetes
• Asthma
• Gallbladder disorder
• Stomach ulcers
• Thyroid disorder
• Thyroid cancer personal or family history
• None of the above

Medications to Purchase

• $399: Semaglutide (2.4 mg)
• $450: Tirzepatide (2.5 mg or 5 mg)
• $650: Tirzepatide (7.5 mg or 10 mg)
• Phentermine 129
• Lipo Burn 3 139
• Lipo Burn 4 139

Consent 1 *

• I have read and give consent to:

CONSENT TO RECEIVE MEDICATIONS
DISCLOSURE OF POSSIBLE SIDE-EFFECTS

Birth City Assigned

Consent 2 *

• I confirm the information provided is accurate and complete

Submit

INTRICATE MIND & BODY, LLC

1155 West 4th Street Ste #103
Reno, Nevada 89503
P: 775-384-2189
F: (775) 384-2254

Laboratory Panel

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Patient Name

First

Last

Date of birth

Name Patient birth

Phone

Select Laboratory Studies

• CBC
• CMP
• Lipid Profile
• Thyroid Profile
• HbA1c

Submit Laboratory Order

Ordering Information

Same day appointments available!!!

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Full Name *

First

Last

Email *

Phone

State

Appointment Date

Appointment Time

Shipping Address Line 1 *

Name Card Time

Shipping Address Line 2

Shipping City *

Shipping State *

Shipping Zip Code *

Billing address is the same as shipping address

• Billing address is the same as shipping address

Cardholder Name *

Card Number *

Expiration Date *

CVC *

Consent

• I have read disclosure of possible side effects
• I consent to receive medication

Confirmation *

• I confirm that the appointment scheduling and ordering details are correct

Submit Appointment Order

INTRICATE MIND & BODY, LLC

Please take the time to measure yourself.
Be sure to date it for comparison later.

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Date

Full name

Date of birth

Gender

Age

Shoulder measurement

Arm measurement

Bust measurement

Waist measurement

Hip measurement

Thigh measurement

Height

Weight

Date Blood Waist

BMI

Blood pressure

Heart rate

Temperature

Submit