Tirzepatide Order Form

Tirzepatide 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.
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
Tirzepatide/B12 Injection
Rush Fee ($50)

YESNO
TIRZEPATIDE/B12 10/1MG/ML (** = holiday pricing)

INITIAL TITRATION: WEEK 1 - 4: Inject 2.5mg (25 units) SQ weekly, WEEK 5 - 8: Inject 5mg (50 units) SQ weekly, 2 X 1.5ML = $200**MAINTENANCE DOSE: Inject 2.5MG (25 units) SQ weekly for 4 weeks, 1.5mL = $180MAINTENANCE DOSE: Inject 5MG (50 units) SQ weekly for 4 weeks, 3mL = $200**MAINTENANCE DOSE: Inject 7.5MG (75 units) SQ weekly for 4 weeks, 3mL = $200**Other, see custom titration option below
TIRZEPATIDE/B12 20/1MG/ML (** = holiday pricing)

MAINTENANCE DOSE: Inject 8MG (40 units) SQ weekly for 4 weeks, 3mL = $300**MAINTENANCE DOSE: Inject 10MG (50 units) SQ weekly for 4 weeks, 3mL = $300**MAINTENANCE DOSE: Inject 13MG (65 units) SQ weekly for 4 weeks, 3mL = $300**MAINTENANCE DOSE: Inject 15MG (75 units) SQ weekly for 4 weeks, 3mL = $300**Other, see custom titration options below
CUSTOM TITRATION/MAINTENANCE DOSE
# OF REFILLS
Would you like to prescribe an additional prescription?

YesNo
CUSTOM TITRATION/MAINTENANCE DOSE
# OF REFILLS
Would you like to prescribe an additional prescription?

YesNo
CUSTOM TITRATION/MAINTENANCE DOSE
# OF REFILLS
Tirzepatide Sublingual Tablets
Rush Fee ($50)

YESNO
TIRZEPATIDE TABLETS (** = holiday pricing)

$150** - INITIAL TITRATION: WEEK 1-4: 3MG SL weekly, WEEK 5-8: 6MG SL weekly (#6 = 60 day supply)$200** - MAINTENANCE: 8MG RDT SL weekly (#4 = 30 day supply)$250** - MAINTENANCE: 12MG RDT SL weekly (#8 = 30 day supply)$300** - MAINTENANCE: 16MG RDT SL weekly (#8 = 30 day supply)Other - please see custom options below
CUSTOM TITRATION/MAINTENANCE DOSE
CUSTOM DOSE PRICING NOTE:

Pricing may vary depending on dose prescribed
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:

Pricing may vary depending on dose prescribed
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:

Pricing may vary depending on dose prescribed
QUANTITY (IN # OF TABLETS)*
Each tablet contains 0.6MG of semaglutide
# OF REFILLS*
Reason for compounding:*

Patient is unable to obtain access to the branded product from their traditional pharmacyPatient’s treatment plan requires a formulation with additional nutritional support (e.g., B12 for enhanced energy and GI support)Patient requires customized dosing schedule that is not available with the branded productPatient has experienced adverse reactions to excipients in the branded productPatient requires a specific dosage form (e.g., rapid dissolving tablets) not offered by the branded productOther - please elaborate below
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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Tirzepatide Order Form

Tirzepatide/B12 Injection

Tirzepatide Sublingual Tablets

CUSTOM DOSE PRICING NOTE:

CUSTOM DOSE PRICING NOTE:

CUSTOM DOSE PRICING NOTE: