INTEREST FORM-Compounded Weight Loss Medications

Compounded Weight Loss Medications Form

Through the years, our pharmacy has been a pillar for our community when things are on shortage. We heard about this shortage & have come up with a solution to help. Skippack Pharmacy is now proud to be offering a compounded form of these medications to our patients. This form will ask you a few questions regarding your medication, history, and basic demographics. You will only have to fill this out ONCE (not for any refills or future script). **AS A THANK YOU FOR FILLING OUT AN INITIAL INTEREST FORM, YOU WILL SEE A $20 COUPON CODE YOU CAN USE ON YOUR ORDER AFTER COMPLETING THIS**
Let's learn a little more about you.

We may know some of you, we may not know others but we'd love to know everyone who we have the opportunity to serve & thus need some information to get you started.
Patient status with Skippack Pharmacy*

I have used Skippack Pharmacy for prescriptionsI have used Skippack Pharmacy for vaccines or testingI am new to Skippack Pharmacy
Who is filling out this form?*

I am filling this out for myselfI am filling this out for my spouse, significant other, family memberI am filling this out for my patient.
How did you hear about us?*

My DoctorA Friend / Family Member / Referred by Another Patient on Weight LossSkippack Pharmacy EmailFacebookInstagramGoogleChatGPTNextdoorWebsiteA News Story (Fox29, NBC, ABC, CBS)Skippack Village (Post/Newsletter)A News Website (NP Now, PV Now, Wiss Now)I Am A Patient of Skippack PharmacyMy Pharmacy Told Me About YouOther
Patient's Name*

First NameLast Name
How Did You Hear About Us / This Program?
Any Additional Detail on the Referral Source? (name of person, provider, etc.) Leave blank if none.
Gender*

FemaleMaleOther
Current Height *
Current Weight *
Date of Birth*

MonthDayYear
Patient Address (if you will be requesting the product be shipped to you, please ensure the address below is your mailing address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Please double check and ensure this is accurate
Cell Phone Number*

Area CodePhone Number
Please list any allergies to medications.
If none, leave blank & move on to the next question.
Do you have a provider who you can get a prescription from?*

Yes, I have a provider (doctor, physician assistant, nurse practitioner, etc.) who will prescribe this medication for me.No, I do not but I would like to connect with a telehealth provider to get a script. Skippack Pharmacy cannot prescribe; however has worked with telehealth providers like Physician 360 who we can refer you to.
Please list the name and city of the DOCTOR/PROVIDER who may prescribe this medication for you (if you will be using a telehealth provider & not sure, write TELEHEALTH)*
Let's get to know you a little more.

The best part about choosing a local pharmacy is that you get to speak to someone you can trust, someone you can reach out to with any issues, someone who wants to see succeed in your goals to better health. **If you don't feel comfortable sharing this information - no problem at all, skip to the next section** The sole purpose to collect this information is to allow us to provide you better service and help you along your journey!
What is your weight loss goal?

Lose 1-20 lbs for goodLose 21-50 lbs for goodLose over 50 lbs for goodMaintain my weight and get fitHaven't decidedOther
What goals are you trying to accomplish?

Lose weightImprove general healthLook betterImprove confidenceIncrease energyOther
What have you tried in the past?

ExerciseDietingWeight loss supplementsIntermittent fastingWeight loss programsWeight loss injectablesOther
Let's talk about the medication.

The best part about choosing a local pharmacy is that you get to speak to someone you can trust, someone you can reach out to with any issues, someone who wants to see succeed in your goals to better health. This information will allow us to provide you better service and help you along your journey!
Which medication are you looking for the compounded formulation of?

OzempicWegovyMounjaroZepboundRybelsusI am not sureOther
What strength of this medication are you looking for?
If not sure, put UNKNOWN
What are the current directions of this medication?
If not sure, put UNKNOWN
What weight loss formulation are you interested in?

Injectable VIAL [You draw up your dose yourself out of a vial into a syringe]Injectable: SYRINGE [Pre-filled syringe that measured doses to inject]Oral [Tablets, Drops, or Troches]
Please select the product that matches the medication you are seeking*

SemaglutideTirzepatideLiraglutideI am not sure about what medication or strength I am supposed to take - I don't have a script but will speak to the provider about this.
Please select the ORAL product that matches the prescription you are seeking*

Oral: Semaglutide 1mg capsulesOral: Semaglutide 3mg capsulesOral: Semaglutide 6mg capsulesOral: Semaglutide 9mg capsulesOral: Semaglutide and B12(cyanocobalamin) 3mg trochesOral: Semaglutide and B12(cyanocobalamin) 6mg trochesOral: Semaglutide and B12(cyanocobalamin) 12mg trochesOral: Semaglutide 1mg/1ml 30mL-vial oral solutionI am not sure about what medication or strength I am supposed to take - I don't have a script but will speak to the provider about this.
Please list the name and city of your CURRENT PHARMACY
If none, leave blank & move on to the next question.
At this time, compounded weight loss medications are not covered by insurance. Are you willing to pay OUT OF POCKET (can use HSA card, credit card, etc.) price is dose dependent and ranges from $179.00 to $649.00 per month supply based on the medication type and amount? Prices are transparent and there are no hidden fees.*

YesNo, I would only like this medication processed through insurance (Do not move forward as unfortunately, we cannot process compounded weight loss medications through insurance).
How would you like to receive the medication once it is ready? You can change your mind and update this when you fill out the payment form.*

Pick up in person - no additional chargeShip to me - +$30 shipping fee
How many months supply would you be interested in getting at once? You can change your mind and update this when you fill out the payment form.

1-month2-month3-monthI'm not sure.
Have you taken any self-injectable before? I.e. Insulin, allergy shots, weight loss injectable, fertility, etc.

Yes, it was pre-filled syringesYes, it was from a vialNo, this is my first timeN/A, I am interested in an oral formulation
Any other information you would like to add to help us help you?
If nothing, leave blank & move on to the last line.
I understand and acknowledge that by filling out this form, I authorize Skippack Pharmacy to provide me with next steps. I will receive an email or click the link on the thank you page for next steps and will move forward with the directions provided therein. I also understand that this product cannot be processed through my insurance & am okay paying out of pocket for it.*

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Compounded Weight Loss Medications Form

Let's learn a little more about you.

Let's get to know you a little more.

Let's talk about the medication.