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 SyrupQty. _____Maple Pancake SyrupQty. _____Maple Walnut Pancake SyrupQty. _____Strawberry Pancake SyrupQty. _____SamplerBreakfast Sampler (7 packets per box)Qty. _____(includes: Omelets, Oatmeal and Pancakes)Coffee CreamerFrench VanillaQty. _____HazelnutQty. _____CaramelQty. _____Protein Drinks Protein Drinks – HotCappuccino 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 – ColdBlue Raspberry Concentrate (7 packets per box)Qty. _____Grape Concentrate (7 packets per box)Qty. _____Green Tea & Cranberry Concentrate (7 packets per box)Qty. _____Mixed Berry 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 and SmoothiesSmoothie Flavor PacksSmoothie Base Mix (7 packets per box) *REQUIRED FOR FLAVOR PACKS*Qty. _____ 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. _____Strawberry Flavor Pack (7 packets per box)Qty. _____Vanilla Bean Flavor Pack (7 packets per box) Qty. _____Variety Pack Mix & 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 Caramel Nut Chewy Protein Bars (7 per box) Qty. _____Caramel Nut Crispy Protein Bars (7 per box) Qty. _____Caramel Sea Salt Crispy Protein Bars (7 per box) Qty. _____Chocolate Crispy Protein Bars (7 per box) Qty. _____Peanut Butter Chewy Protein Bars (7 per box) Qty. _____Peanut Butter Crispy 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 Crispy Protein Bars (7 per box) Qty. _____Vanilla Chewy Protein Bars (7 per box) Qty. _____Vanilla Crispy Protein Bars (7 per box) Qty. _____Variety Pack Crispy Protein Bars (7 per box) Qty. _____Zesty Lemon Crispy Protein Bars (7 per box) Qty. _____Sweet SnacksShake/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. _____Raspberry Wafers (5 per box) Qty. _____Savory Snacks 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. _____SoupsHot Base Soup Mix (7 packets per box) *REQUIRED FOR FLAVOR PACKS*Qty. _____ 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. _____Variety Soup Mix (7 packets per box) Qty. _____(Includes: 1 Cream of Chicken, 1 Cream of Mushroom, 1 Cream of Vegetable, 1 Italian Tomato and 2 Chicken Noodle)Entrées7 Day EntreesChicken Alfredo Pasta Entrée (7 packets per box) Qty. _____Creamy Mac & Cheese Entrée (7 packets per box)Qty. _____Garlic & Herb Sauce Packets (for Fusilli) (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 Stroganoff Entrée (1 entrée) Qty. _____Chicken Enchilada Verde Entrée (1 entrée) Qty. _____Chicken Pasta Entrée (1 entrée) Qty. _____Five Bean Casserole Entrée (1 entrée) Qty. _____Gravy with Beef Pot Roast 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. _____ExtrasAccessoriesMetTrimMD Blender Bottle (1 bottle) Qty. _____Success Guide Qty. _____The Beck Diet Solution Book Qty. _____BioFX Energy PowderBerry (14 packets)Qty. _____Lime (14 packets)Qty. _____Orange (14 packets)Qty. _____Cleansing HerbsHerbal Tea (20 tea bags)Qty. _____FIBERightTropical Fruit (10 packets)Qty. _____KetoFXBerry (14 packets)Qty. _____Orange(14 packets)Qty. _____SmartForme Fiber PowderUnflavored (14 packets)Qty. _____SupplementsBalance (30 capsules)Qty. _____CLA (60 capsules)Qty. _____Probiotics (30 capsules)Qty. _____SOMA-EFA ‘Fish Oil’ (120 Capsules) Qty. _____SOMA-Vit Vitamin (30 tablets) Qty. _____SmartSlim Hunger Suppressant (90 Capsules) Qty. _____ThermoCaps Metabolism Booster (90 Capsules) Qty. _____Vitamin D3 (60 capsules)Qty. _____Water Relief (90 capsules)Qty. _____ ................
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