Semaglutide/Tirzepatide Self-Order

Name*

First NameLast Name

Date of Birth*

Date

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

I am a CURRENT weight loss patient of Dawson Integrative Medical Center 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

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.*

I understand

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

I have seen the nurse practitioner within the past 3 months.*

I understand

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).*

I understand

Please select which medication you would like to order. Please note that this must be the SAME dosing as your last fill (we can adjust dosing without an appointment) and that you must have been seen within the last 3 months to be eligible to self order. If you are on any other dose than what is listed below, you are not eligible. Please select your medication:*

How many vials would you like to order? Remember, depending on when your last appointment was, you may be restricted but you can select the amount you wish to order to submit for approval. Please note that vials typically expire 28-30 days after it has been compounded.*

1 vial

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:*

I agree

*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

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 either $125 for the office visit or $100 late cancelation/no show fee. I understand that I am able to keep any appointment if I agree to pay the $125 office visit fee 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 Medical Center, 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. The turn around time is based on this date.

Signature*

Date*

Date