Semaglutide/Tirzepatide Self-Order

Name

First NameLast Name

Address for medication to be shipped to (must match what is on file)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

STOP! PLEASE DO NOT GO ANY FURTHER IF YOU HAVE NOT BEEN SEEN IN THE LAST 90 DAYS, IF YOU ARE IN TITRATION OR NEED A DOSING ADJUSTMENT. Please enter your last appointment visit date here. Your request will automatically be DENIED if you have not been seen in the last 3 months OR if you are not eligible for self orders.

I am a CURRENT weight loss patient of Dawson Integrative & Functional Medicine, LLC and I have been seen by the nurse practitioners in the last 3 months. If you are not a current patient or have not been seen by the nurse practitioners in the last 3 months, please STOP here and proceed to schedule an appointment. I understand that I am allowed to self order 2 times in between visits and I must be seen on the 3rd order.

Self-ordering medication refills are only valid for the last dosing you were prescribed. You understand that we cannot do dosing adjustments without an appointment with the nurse practitioner. We will automatically process the SAME order you last received. TIRZEPATIDE PRICING: 2.5mg $275; 5mg $325; 7.5mg $375; 10mg $425; 12.5mg $450; 15mg $480 SEMAGLUTIDE PRICING: 0.25mg $250; 0.50mg $270; 1mg $295; 1.7mg $305; 2.5mg $315

Self-ordering medication refills are only able to be done if you are a current, consistent patient that has been on medications for the past 3 months with us. You must have been on our program for at least 3 months and no longer in the ramp up phase. I understand that I am allowed to self order 2 times in between visits and I must be seen on the 3rd order. You also must be eligible for self orders.

I have seen the nurse practitioner within the past 3 months. I understand I am able to self order 2 times in between visits and I must be seen on the 3rd order (sooner if not eligible for self orders).

You understand that self-ordering medication refills DOES NOT include a visit with the nurse practitioner and that is a separate fee of $125 if you decide to see the nurse practitioner when not ordering medication. (Basically this option allows you to self-order medications without an appointment and is NOT all-inclusive).

You agree to have the card on file charged with the above amount, I agree there are no refunds, exchanges, returns or credits and all sales are final:

*WE WERE ABLE TO SECURE LOWER PRICES ON THESE MEDICATIONS BY PLACING THE ORDERS IN BULK. ALL COMPOUNDED WEIGHT LOSS MEDS WILL BE PLACED EVERY FRIDAY (REGARDLESS OF WHEN YOUR APPOINTMENT IS OR WHEN YOU'VE PLACED THIS ORDER-PHARMACY TURN TIME STARTS THEN).*

I agree to self-order the medication above. I agree that my request will be denied if I am requesting a dose other than my most recent prescription and that any changes need to be discussed during an office visit only with the nurse practitioner. I understand that the self-ordering option does not include an office visit and that I am responsible for canceling any upcoming visit with the nurse practitioner with a 48-hour notice to avoid being charged a fee FEE EQUAL TO THE FULL COST OF MY APPOINTMENT charged to my credit card on file. I understand that I am expected to pay the $125 office visit fee for appointments attended or if I am renewing an all-inclusive package. I understand that I have to be seen by the nurse practitioner every 3 months in order to continue with the program and be eligible for self-ordering. **This does not apply to patients to have a gap or lapse in treatment of greater than 4 weeks. You must see the nurse practitioner to reorder.**

I agree to have Dawson Integrative & Functional Medicine, LLC charge the card for the medication and the medication amount stated above. I understand there are absolutely NO REFUNDS, CREDITS OR EXCHANGES.

I understand that while current turn times for pharmacy processing is about 5 business days, at times the turn-around time for processing medications could be 10-14 business days.

I have confirmed the address above to be the shipping address for my medications.

**Compounded weight loss medication orders are placed every Friday MORNING at 8am. Your payment is processed immediately. If your order is received after orders have been submitted for the week, your order will go to the pharmacy on the following Friday. It is best to have all orders in on Thursday evening. The turn around time is based on the date and time that you submit your order; which can be up to 14 business days.

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