Customized Weight loss Medications Intake Form

Customized Weight loss Medications Intake Form
At Lititz Apothecary, finding personalized solutions for our community is at the heart of what we do. As an independent pharmacy, we offer compounded semaglutide and tirzepatide — injectable GLP-1 medications customized to your individual dosing needs by our team.

This form will ask you a few questions to help us understand your goals and tailor a program that works for you. Compounded medications are not manufactured by or affiliated with any pharmaceutical brand and are prepared in compliance with applicable compounding regulations.

Cost:
• Injectable: Starting at $150 every 4 weeks, adjusted based on dosage

Overall Process:

Once you complete this form, an onboarding specialist will reach out to go over the details.

1. You may reach out to your provider (doctor's office) and our team is available to answer any clinical questions your provider may have.

2. Once the prescription is received, we will contact you to set a time with a clinician to go over injection techniques, best practices, and frequently asked questions.

3. When you are due for a refill, our staff will contact you 3–5 days in advance to review your progress and prepare the next month's dosage.
Patient's Name

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth*

MonthDayYear
Email*
example@example.com
Cell Phone Number*
Format: (000) 000-0000.
List name and city of Doctor/Provider who prescribes this type of medication for you*
Please indicate a few dates and times a specialist can reach-out to answer any questions and process?*
How did you hear about us?*
Pick up in Person- No additional chargeDeliver/Ship it to me - $20 Fee
Any other information you would like to add?
I understand and acknowledge that I will have my prescriber send a script to Lititz Apothecary only if I am informed to do so. I understand and acknowledge that Lititz Apothecary can and will advocate on your behalf and have a clinical conversation with the prescriber. Lititz Apothecary will not be able to dispense medication without a valid prescription.*
Date Signed *

MonthDayYear
Date
Should be Empty: