PatientPop



Telemedicine Patient Order FormPlease print this form and fill in your selections, then scan and forward your completed order form to dallasteam@If you have any questions, please contact our office via phone at 469-801-8480 or the email provided above.BreakfastCerealCinnamon Cereal (5 packets per box) Qty. _____Honey Nut Cereal (5 packets per box) Qty. _____OatmealApple Cinnamon Oatmeal (6 packets per box) Qty. _____Maple Brown Sugar Oatmeal (6 packets per box) Qty. _____Omelet MixesBacon & Cheese Omelet Mix (7 packets per box) Qty. _____Cheese & Chive Egg Scramble Mix (7 packets per box) Qty. _____Vegetable Omelet Mix (7 packets per box) Qty. _____Southwestern Omelet Mix (7 packets per box) Qty. _____Pancake Mix and SyrupBlueberry Pancake Mix (7 packets per box) Qty. _____Chocolate Chip Pancake Mix (7 packets per box) Qty. _____Original Pancake Mix (7 packets per box) Qty. _____Blueberry Pancake Syrup Qty. _____Maple Pancake Syrup Qty. _____Maple Walnut Pancake Syrup Qty. _____Strawberry Pancake Syrup Qty. _____SamplerBreakfast Sampler (7 packets per box) Qty. _____(includes: Omelets, Oatmeal and Pancakes)Coffee CreamerFrench Vanilla Qty. _____Hazelnut Qty. _____Caramel Qty. _____Protein Drinks (Hot and Cold – Concentrate and Powder Mix)Protein Drinks – Hot ConcentrateCappuccino Drink Mix (7 packets per box) Qty. _____Hot Chocolate Drink Mix (7 packets per box) Qty. _____Pumpkin Spice Latte (7 packets per box) Qty. _____Protein Drinks – Cold ConcentrateBlue Raspberry Concentrate (7 packets per box) Qty. _____Grape Concentrate (7 packets per box) Qty. _____Green Tea & Cranberry Concentrate (7 packets per box) Qty. _____Strawberry Banana Concentrate (7 packets per box) Qty. _____Protein Drinks - Powder MixPink Lemonade Powder (7 packets per box) Qty. _____Peach Mango Tea Powder (7 packets per box) Qty. _____Berry Blast Powder (7 packets per box) Qty. _____Orange Powder (7 packets per box) Qty. _____Protein ShotsApple Protein Shot (1 bottle) Qty. _____CranGrape Protein Shot (1 bottle) Qty. _____Orange Protein Shot (1 bottle) Qty. _____Pink Lemonade Protein Shot (1 bottle) Qty. _____Protein Shakes (Breakfast, Lunch and/or Dinner Option)Smoothie Flavor PacksSmoothie Base Mix (7 packets per box) Qty. _____ *REQUIRED FOR ALL FLAVOR PACKS*Blueberry Delight Flavor Pack (7 packets per box) Qty. _____Chocolate Indulgence Flavor Pack (7 packets per box) Qty. _____Pina Colada Flavor Pack (7 packets per box) Qty. _____Smoothie Variety Pack Mix & Flavor Pack (7 packets per box) Qty. _____Vanilla Bean Flavor Pack (7 packets per box) Qty. _____Bottled Shake MixChocolate Bottled Shake Mix (6 bottles) Qty. _____Chocolate Salted Caramel Bottled Shake Mix (6 bottles) Qty. _____Lemon Razzy Bottled Shake Mix (6 bottles) Qty. _____Mango Splash Bottled Shake Mix (6 bottles) Qty. _____Vanilla Bottled Shake Mix (6 bottles) Qty. _____Wild Berry Splash Bottled Shake Mix (6 bottles) Qty. _____Ready to Serve ShakesCafé Latte Ready to Serve Shake (6 bottles) Qty. _____Chocolate Ready to Serve Shake (6 bottles) Qty. _____Field Berry Ready to Serve Shake (6 bottles) Qty. _____Vanilla Ready to Serve Shake (6 bottles) Qty. _____High Protein ShakesVanilla High Protein Mix (7 packets per box) Qty. _____Protein Bars (Mid-Morning and/or Mid-Afternoon Snack Option)Caramel Nut Protein Bars (7 per box) Qty. _____Caramel Nut CHEWY Protein Bars (7 per box) Qty. _____Caramel Sea Salt Protein Bars (7 per box) Qty. _____Chocolate Crisp Protein Bars (7 per box) Qty. _____Peanut Butter CHEWY Protein Bars (7 per box) Qty. _____Peanut Butter Crisp Protein Bars (7 per box) Qty. _____Rocky Road CHEWY Protein Bars (7 per box) Qty. _____Salted Toffee Pretzel Protein Bars (7 per box) Qty. _____Strawberry Shortcake Crisp Protein Bars (7 per box) Qty. _____Vanilla Crisp Protein Bars (7 per box) Qty. _____Vanilla CHEWY Protein Bars (7 per box) Qty. _____Variety Pack CHEWY Protein Bars (7 per box) Qty. _____Zesty Lemon Crisp Protein Bars (7 per box) Qty. _____Sweet Snacks (Mid-Morning and/or Mid-Afternoon Snack Option)Shake/Pudding MixCaramel Café Latte Shake/Pudding Mix (7 per box) Qty. _____Chocolate Shake/Pudding Mix (7 per box) Qty. _____Strawberry Shake/Pudding Mix (7 per box) Qty. _____Vanilla Shake/Pudding Mix (7 per box) Qty. _____Gelatin MixRaspberry Gelatin Mix (7 per box) Qty. _____Strawberry Banana Gelatin Mix (7 per box) Qty. _____Soy SnacksChocolate Soy Snacks (7 per box) Qty. _____Peanut & Caramel Soy Snacks (7 per box) Qty. _____Brownies, Cookies, Granola and Wafer SnacksSoft Baked Brownie Mix (7 per box) Qty. _____Chocolate Chip Cookies (7 per box) Qty. _____Oatmeal Raisin Cookies (7 per box) Qty. _____Chocolate Sandwich Cookies (7 packs per box) Qty. _____Chocolate & Caramel Granola Snacks (7 packs per box) Qty. _____Chocolate Wafers (5 per box) Qty. _____Lemon Wafers (5 per box) Qty. _____Raspberry Wafers (5 per box) Qty. _____Savory Snacks (Mid-Morning and/or Mid-Afternoon Snack Option)Barbeque Crunch Chips (1 bag) Qty. _____Pizza Crunch Chips (1 bag) Qty. _____Ranch Crunch Chips (1 bag) Qty. _____Spicy Nacho Cheese Crunch Chips (1 bag) Qty. _____Chipotle BBQ Zipper Snacks (7 per box) Qty. _____Sour Cream & Fine Herb Zipper Snacks (7 per box) Qty. _____Soups (Lunch and/or Dinner Option)Hot Base Soup Mix (7 packets per box) Qty. _____ *REQUIRED FOR ALL SOUPS*Cheddar & Broccoli Flavor Pack (7 packets per box) Qty. _____Chicken & Vegetable Flavor Pack (7 packets per box) Qty. _____Chicken Noodle Soup Mix (7 packets per box) Qty. _____Cream of Chicken Soup Mix (7 packets per box) Qty. _____Cream of Mushroom Soup Mix (7 packets per box) Qty. _____Italian Tomato Soup Mix (7 packets per box) Qty. _____Entrées (Lunch or Dinner Option)7 Day EntreesAsian Inspired Sauce Entrée (7 packets per box) Qty. _____Chicken Alfredo Pasta Entrée (7 packets per box) Qty. _____Creamy Mac & Cheese Entrée (7 packets per box) Qty. _____High Protein Fusilli Entrée (7 packets per box) Qty. _____Vegan Chicken Curry Entrée (7 packets per box) Qty. _____Vegetable Chili Entrée (7 packets per box) Qty. _____Spaghetti Bolognese (7 packets per box) Qty. _____Individual EntreesBeef Pot Roast Entrée (1 entrée) Qty. _____Beef Stroganoff Entrée (1 entrée) Qty. _____Chicken Enchilada Verde Entrée (1 entrée) Qty. _____Chicken Pasta Entrée (1 entrée) Qty. _____Green Pepper Steak Entrée (1 entrée) Qty. _____Pasta Fagioli Entrée (1 entrée) Qty. _____Spaghetti & Meatballs Entrée (1 entrée) Qty. _____Spicy Chicken Oriental (1 entrée) Qty. _____Turkey Chili Entrée (1 entrée) Qty. _____Vegetable Lasagna Entrée (1 entrée) Qty. _____Vegetable Stew Entrée (1 entrée) Qty. _____5 Bean Casserole Entrée (1 entrée) Qty. _____ExtrasSupplementsThermoCaps Metabolism Booster (90 Capsules) Qty. _____SmartSlim Hunger Suppressant (90 Capsules) Qty. _____SOMA-Vit Vitamin (30 tablets) Qty. _____SOMA-EFA ‘Fish Oil’ (120 Capsules) Qty. _____AccessoriesMetTrimMD Blender Bottle (1 bottle) Qty. _____Success Guide Qty. _____The Beck Diet Solution Book Qty. _____ ................
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