Weight Loss

Name*

First NameMiddle NameLast Name

Physical Address*

Street Address

Apt #

CityState Initials

Zip Code

Date of Birth*

Gender *

Email*

example@example.com

Phone Number*

Format: (000) 000-0000.

Screen Questions for Weight loss medication*

Rows	Yes	No
Family/personal history of medullary thyroid carcinoma
History of pancreatitis OR GI Diseases
Known hypersensitivity to tirzepatide or semaglutide
Family or personal history of Multiple Endocrine Neoplasia Type 2
Have or have had problems with your pancreas or kidneys or Diabetic Retinopathy
Are pregnant or breastfeeding or plan to become pregnant or breastfeed

Weight Loss medication request*

SemaglutideOther

At this time, compounded semaglutide is not covered by insurance. Are you willing to pay OUT OF POCKET (You may use HSA card, credit card, etc.) price is dose dependent and ranges from $179.00 to $399.00 per month supply based on the medication type and amount? Prices are transparent, there are no hidden fees, and are the prices listed in the table above.*

YesNo

I understand and acknowledge that by filling out this form, I authorize Caplet Pharmacy to guide me. I also understand that this product cannot be processed through my insurance & will be paying out of pocket for it.*

Date Signed

Date

Immunizer Name

First and Last Name

Immunizer Signature

Lot Number

Pharmacy Name

Pharmacy NPI*

Do you have a provider who you can get a prescription from?

Rows	Check each box
Yes, I have a provider (doctor, nurse practitioner, etc.) who will prescribe this medication for me.
No, I do not but I will get a script through a telehealth provider. Caplet Pharmacy cannot prescribe; however has worked with telehealth providers like Physician 360 who we can refer you to.