Semaglutide Order Form

Semaglutide Order Form

Please fill out form in its entirely; may cause delays in processing otherwise
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Medication Allergies*
Describe Medication Allergies
If Applicable
Billing Instructions*

CLINICPATIENT
Delivery Instructions*

CLINICPATIENT
Facility Name
Provider Email (for form receipt)
To access receipt, password is St0negate!
Facility Address

Street Address

Street Address Line 2

CityState

Zip Code
Which formulation would you like to prescribe?*

Injection onlyRapid dissolve tablet onlyBoth
Semaglutide Injection
Rush Fee ($50)

YESNO
Addition of Cyanocobalamin 1mg/ml

YESNO
SEMAGLUTIDE 5MG/ML

INITIAL TITRATION: WEEK 1 - 4: Inject 0.25mg (5 units) SQ weekly, WEEK 5 - 8: Inject 0.5mg (10 units) SQ weekly, WEEK 9 -12: Inject 1.0mg (20 units) SQ weeklyMAINTENANCE: Inject 0.25MG (5 units) SQ weekly for 4 weeksMAINTENANCE: Inject 0.5MG (10 units) SQ weekly for 4 weeksMAINTENANCE: Inject 1MG (20 units) SQ weekly for 4 weeksMAINTENANCE: Inject 1.7MG (34 units) SQ weekly for 4 weeksMAINTENANCE: Inject 2.4MG (48 units) SQ weekly for 4 weeksOther, see custom titration options below
CUSTOM TITRATION/MAINTENANCE DOSE
UNIT CONVERSION CHART
QUANTITY (** = holiday pricing)
# OF REFILLS
Would you like to prescribe an additional prescription?

YesNo
CUSTOM MAINTENANCE DOSE
UNIT CONVERSION CHART
QUANTITY
# OF REFILLS
Would you like to prescribe an additional prescription?

YesNo
CUSTOM MAINTENANCE DOSE
UNIT CONVERSION CHART
QUANTITY
# OF REFILLS
Semaglutide Sublingual Tablets
Rush Fee ($50)

YESNO
SEMAGLUTIDE TABLETS

$150 - INITIAL TITRATION: WEEK 1-4: 0.3MG SL weekly, WEEK 5-8: 0.6MG SL weekly, WEEK 9 -12: 1.2MG SL weekly (#14 = 90 day supply)$100 - MAINTENANCE: 1.2MG RDT SL weekly (#4 = 30 day supply)$100 - MAINTENANCE: 2MG RDT SL weekly (#4 = 30 day supply)$100 - MAINTENANCE: 2.8MG RDT SL weekly (#4 = 30 day supply)$150 - MAINTENANCE: 4MG RDT SL weekly (#4 = 30 day supply)Other - please see custom options below
CUSTOM TITRATION/MAINTENANCE DOSE
CUSTOM DOSE PRICING NOTE:

$150 if less than 6 tablets, $200 if 7-12 tablets
QUANTITY (IN # OF TABLETS)*
Each tablet contains 0.6MG of semaglutide
# OF REFILLS*
Would you like to prescribe an additional prescription?

YesNo
CUSTOM TITRATION/MAINTENANCE DOSE
CUSTOM DOSE PRICING NOTE:

$150 if less than 6 tablets, $200 if 7-12 tablets
QUANTITY (IN # OF TABLETS)*
Each tablet contains 0.6MG of semaglutide
# OF REFILLS*
Would you like to prescribe an additional prescription?

YesNo
CUSTOM TITRATION/MAINTENANCE DOSE
CUSTOM DOSE PRICING NOTE:

$150 if less than 6 tablets, $200 if 7-12 tablets
QUANTITY (IN # OF TABLETS)*
Each tablet contains 0.6MG of semaglutide
# OF REFILLS*
ADDITIONAL COMMENTS/REQUESTS
Provider Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Provider NPI*
Provider DEA*
Signature*

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Semaglutide Order Form

Semaglutide Injection

Semaglutide Sublingual Tablets

CUSTOM DOSE PRICING NOTE:

CUSTOM DOSE PRICING NOTE:

CUSTOM DOSE PRICING NOTE: