Compounded Semaglutide/ Tirzepatide Inquiry

Since 2022, many type 2 diabetes and weight-loss injectables (including, but not limited to Wegovy, Mounjaro, Ozempic, Saxenda, and Zepbound) have been on a national shortage. We have received a surge of phone calls in the past months from concerned patients and providers seeking to find a medication they cannot abruptly stop, or from patients looking to start new therapies. As an independent pharmacy who strives to help our community navigate through healthcare challenges, we wanted to find alternatives that support our patients’ goals.

Lititz Apothecary has completed due dilligance in compounding GLP1 medication from FDA approved facilities. Injectable Semaglutide and Terzepatide is now available.

Cost:

o Injectable: Starting at $300 every 4 weeks

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*

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?*

Please Select the product that matches the prescription you are seeking.

Semaglutide (same active ingredient as Ozempic or Wegovy 0.25mg-0.5mg)Semaglutide (same active ingredient as Ozempic or Wegovy 1mg-2.4mg)Tirzepatide 10mg/ml (same active ingredient as Mounjaro and Zepbound 2.5mg- 5mg)Tirzepatide 10mg/ml (same active ingredient as Mounjaro and Zepbound 5mg- 10mg)Tirzepatide 20mg/ml (same active ingredient as Mounjaro and Zepbound 12.5mg- 15mg)Other

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

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.*

Date Signed *

Date