Compounded Weight Loss Medications Form

Compounded Weight Loss Medications Form
Since 2022, many weight loss medications have gone on shortages and as a indepedent pharmacy and a pillar of the community finding solutions is at the heart of what we do. This form will ask you a few questions to help educate and tailor a program to what works for you.

Cost:

o Injectable: Starting at $215 every 4 weeks, increased based on dosage

Overall Process:

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

1. You may reach out to your Provider (doctor's office) AND the pharmacy will reach out to the provider as well (advocating on your behalf)

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 other FAQ.

3. When you are due for a refill, our staff will contact you, 3-5 days in advance to go over 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*
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?*
How would you like to receive the medication once it is ready?

Pick up in Person- No additional chargeDeliver/Ship it to me - $30 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.*

Clear
Date Signed *

MonthDayYear
Date
Should be Empty: