Gula World Consultation
Step
1
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7
14%
This form will be sent to our Physician for review.
What are your goals?
(Required)
Check ALL that apply*
Weight Loss
Erectile Dysfunction
Sleep
Pain (Inflammation)
Mental Health (Stress, Depression, Anxiety)
Hair Replacement
Is this your first Home Kit?
(Required)
New Patient
Existing Patient
This form will be sent to our Physician for review.
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Which options would you like?
All Homekits are a 1 month supply. Each Homekit must be opened at delivery and refrigerated upon arrival. (In addition to shipping, our current order processing time is 2-5 days)
Benzocaine 20%/Lidocaine 10%/Tetracaine 10% cream Telemedicine physician consolation
Quantity
Price:
$159.00
Quantity
Benzocaine 20%/Lidocaine 4%/Tetracaine 5% cream Telemedicine physician consolation
Quantity
Price:
$159.00
Quantity
Benzocaine 20%/Lidocaine 6%/ Tetracaine 4% cream- Telemedicine physician consolation
Quantity
Price:
$159.00
Quantity
Benzocaine 20%/Lidocaine 8%/Tetracaine 6% cream- Telemedicine physician consolation
Quantity
Price:
$159.00
Quantity
ED -Sildenafil/Tadalafil (combo) troches- Telemedicine physician consultation. 25 unities in a bottle
Quantity
Price:
$390.00
Quantity
ED -Sildenafil/Tadalafil/Apomorphine troches- Telemedicine physician consultation. 25 unities in a bottle
Quantity
Price:
$390.00
Quantity
ED Penile Injections (Papaverine/Phentolamine/Alprostadil)- Telemedicine Physicians Consultation
Quantity
Price:
$598.00
Quantity
Ibutamoren (Mk 677) 25mg
Quantity
Price:
$45.95
Quantity
Ibutamoren (Mk 677) 50mg
Quantity
Price:
$56.95
Quantity
Immune booster Kit (IV only) - Telemedicine physician consultation
Quantity
Price:
$759.00
Quantity
Inner Beauty IV Kit (Fortify hair, skin, nails)
Quantity
Price:
$986.00
Quantity
Libido And Energy Enhancer IV Kit (Get Up and Go Kit) Telemedicine Physicians Consultation
Quantity
Price:
$665.62
Quantity
Lipo-Mino IV Kit with L- Carnitine (similar To Skinny Drip)- Telemedicine Physicians Consultation
Quantity
Price:
$564.37
Quantity
Lipo-Mino IV Kit without L- Carnitine (similar To Skinny Drip)- Telemedicine Physicians Consultation
Quantity
Price:
$547.50
Quantity
MICC Injection (includes B12)-Telemedicine Physicians Consultation - 10ml
Quantity
Price:
$294.48
Quantity
MICC Injection (includes B12)-Telemedicine Physicians Consultation - 30ml
Quantity
Price:
$553.86
Quantity
Myers cocktail (Premix)- 10ml
Quantity
Price:
$378.75
Quantity
NAD+ Injection 500mg lyophilized - Telemedicine Physicians Consultation
Quantity
Price:
$495.00
Quantity
Oxytocin 400 Ui/mL nasal spray- Telemedicine physician consultation
Quantity
Price:
$176.50
Quantity
Phentermine 13mg/Carnitine 150mg capsules
Quantity
Price:
$19.90
Quantity
Phentermine 37.5mg capsules
Quantity
Price:
$19.90
Quantity
Quench IV Kit
Quantity
Price:
$1,082.00
Quantity
Recovery and Performance IV KIT
Quantity
Price:
$951.00
Quantity
Scream Cream (vaginal) - Telemedicine physician consultation -Women
Quantity
Price:
$176.00
Quantity
Scream Cream (vaginal) - Telemedicine physician consultation -Women
Quantity
Price:
$199.50
Quantity
Semaglutide- Injection - telemedicine physician consultation - 1ml
Quantity
Price:
$349.85
Quantity
Semaglutide- Injection - telemedicine physician consultation - 2ml
Quantity
Price:
$515.00
Quantity
Semaglutide- Injection - telemedicine physician consultation - 5ml
Quantity
Price:
$1,225.00
Quantity
Sildenafil troches- Telemedicine Phisician consultation 25 units in a bottle
Quantity
Price:
$314.00
Quantity
Tadalafil gummies- Telemedicine physician consolation -25 in a bottle
Quantity
Price:
$314.00
Quantity
Testosterone Blend Injection Compound Cypionate- Telemedicine physician consultation
Quantity
Price:
$325.00
Quantity
Testosterone Injection Compound Cypionate- Telemedicine physician consultation
Quantity
Price:
$345.00
Quantity
Testosterone Injection Compound Cypionate- Telemedicine physician consultation
Quantity
Price:
$267.00
Quantity
Testosterone troche- Telemedicine physician consultation- 25 tablets
Quantity
Price:
$271.87
Quantity
Tri Immune Boost IM/IV 30mL (Cold Ship Item) 30ml
Quantity
Price:
$69.00
Quantity
Subtotal
Shipping
Choose a Shipping Option:
(Required)
FedEx Overnight (1 Business Day, Mon-Thurs) + $22.00
FedEx Priority Overnight (1 Business Day, Mon-Thurs, AM delivery) + $42.00
Coupon (Not Valid for SALE products)
Notes
Total
This form will be sent to our Physician for review.
Date of Birth
(Required)
dd/mm/yyyy
Height
(Required)
Feet and Inches (Example: 5' 1")
Weight (lbs)
(Required)
Race
(Required)
(We ask this because some populations are more susceptible to certain conditions than others.)
Sex
(Required)
Male
Female
Allergies
(Required)
What is your occupation?
(Required)
Past Medical and Surgical History
Please fill out as completely as possible.
Do you have any of the following conditions?
Check ALL that apply
Fibromyalgia
Chronic Fatigue Syndrome
Liver or Kidney problems
Heart Problems
High Blood Pressure
Thyroid Issues
Hormone Issues
Blood Clots
Pre/Peri/Post Menopause
Cancer
Stroke or Seizure
None
Select All
Do you have pancreatitis or a history of pancreatitis?
(Required)
Yes
No
Do you have medullary thyroid cancer or a history of medullary thyroid cancer?
(Required)
Yes
No
Do you have renal (kidney) impairment?
(Required)
Yes
No
Do you have type 1 diabetes or diabetic retinopathy?
(Required)
Yes
No
Are you taking any blood thinners?
(Required)
Yes
No
Prescription Medications OR Non-Prescription Supplements you are currently taking:
(Required)
Do you have any new prescription Medications OR Non-Prescription Supplements you are currently taking?
(Required)
Do you drink alcohol?
(Required)
Yes
No
It is not recommended that you consume alcohol on the same day of your injection.* I Understand
Phone Number
(Required)
This is the Phone Number the Doctor will use to call you, if necessary. Please double check to make sure that it is correct.
Billing Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Shipping Address
(Required)
Same as billing address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
License or Government ID
Max. file size: 50 MB. If you are unable to upload, please email it to connect@gulaworld.com
Max. file size: 50 MB.
REQUIRED "HOW TO" VIDEO
(Required)
Video Available here: https://gulaworld.com/pages/howtoinject
I have watched the video and know how to give myself an injection
I WILL FOLLOW THE INSTRUCTIONS AND DOSAGE AMOUNTS ON MY BOTTLE. I understand these injections are to be self-injected in the area written on my bottle. I will watch the video to learn how to self-inject. I am aware the instructional video is available to watch at
https://gulaworld.com/pages/howtoinject
.
I agree I will use the syringes and vitamins as directed.
(Required)
I Agree
I understand that my custom package is ordered for me. My vial or package I start at Gula World product will have an expiration date that is 30 days after opening. I understand, after the 30-day period, medications are considered expired and should be discarded by me.
(Required)
I Agree
CONSENT FORM: I acknowledge that I have received instructions and educational material from gulaworld for the administration of home injections. I acknowledge that the risks of injections have been discussed with me. I understand that these risks include, but are not limited to, local reactions, rashes, bruises, etc. - I understand that if I elect to do self-administered injections or if another designated individual gives me the injection, I should be attended for at least 30 minutes by a responsible adult to assist me in case of a severe reaction. - I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I acknowledge that I have received instructions on its use and administration. I further understand that I must identify that the date of this medication is current. If not, I will call for a renewal of my medication. - I understand that it is my responsibility to maintain follow-up appointments with my physician at gulaworld as needed. By signing this form, I assume full responsibility for receiving my injections and release Gulawold and its physicians from any liability or responsibility for any reactions, conditions, self-injection procedures, or injuries in conjunction with the injection therapies.
(Required)
I Agree
I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY AVAILABLE AT
https://gulaworld.com/pages/refund-policy
.
I authorize Gulaworld to charge my credit card for agreed-upon purchases. I understand that my information will be saved to file for future transactions on my account.
(Required)
I Agree
I agree to give my consent to treatment. I have read the Telehealth Consent located at
https://gulaworld.com/pages/refund-policy
.
I Agree
(Required)
I Agree
I agree to GulaWorld Terms and Conditions. I have read the Terms and conditions located at
https://gulaworld.com/pages/terms-and-conditions
.
I agree to GulaWorld Terms and Conditions.
(Required)
I Agree
PRINT NAME. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)
(Required)
Signature
(Required)
Date SIGNED (mm/dd/yyyy)
(Required)
MM slash DD slash YYYY
Total
Credit Card
(Required)
Please check your Stripe API Settings. Click the "Connect with Stripe" button to use Stripe.
ONE-TIME OR SUBSCRIPTION ORDER?
(Required)
You can choose to make this order a one-time order or plan to get it delivered every month.
ONE-TIME ORDER ONLY
RECURRING SUBSCRIPTION MONTHLY (Subscription will be charged on this day every month. Cancel anytime before next billing by emailing connect@gulaworld.com)
***IMPORTANT*** YOU ARE AGREEING TO A SUBSCRIPTION PROGRAM
(Required)
I AGREE TO A MONTHLY SHIPMENT AND AUTOMATIC BILLING TO MY CREDIT CARD ON THIS DAY EVERY MONTH
Create an Account
Registration required for new patients
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Password
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Enter Password
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