Weight Loss
Name
*
First Name
Middle Name
Last Name
Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender
*
Please Select
Male
Female
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
*
Semaglutide
Other
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.
*
Yes
No
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
/
Month
/
Day
Year
Date
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Pharmacy Name
Pharmacy NPI
*
Preview PDF
Submit Consent Form (required)
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.
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