WEIGHT LOSS INJECTABLE/ORAL FORMULATION PAYMENT FORM
Please complete this form to order your compounded semaglutide or tirzepatide prescription for pick up at Skippack Pharmacy. This product is not covered by insurance and will be available out of pocket. Patients are responsible for the cost of the medication up front. This is NOT a hold on your credit card, by inputting your credit card number below, you will be charged immediately. Please contact us at clinic@skippackpharmacy.com prior to submitting if you have any questions! Once the order is placed through this form, you acknowledge there are no refunds. ***BOOKMARK THIS PAGE: We cannot put your card on file so you will have to fill out a new payment form when you need a refill --> you will use this same payment link for your initial medication & for refills for following months***
RECEIVING YOUR MEDICATION
Based on if you select if you would like it shipped or pick up in store, you will be notified from our team. If picking up in store, please come to Skippack Pharmacy to pick-up your prescription ONLY AFTER receiving an email or text that it is ready. You do not need to reach out to us --- we will be in touch with you the moment your medication is ready. Our pick-up hours are Mondays-Fridays 10 AM to 7 PM and Saturdays 10AM to 2PM. If you requested for it to be shipped, we will email you with tracking information once the RX is ready.
Name
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First Name
Last Name
Birthdate
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Email **non Comcast.net email preferred as Comcast email addresses have often gone to spam**
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example@example.com
Is this your first time ordering injectables/oral formulation or are you getting a refill or additional fill?
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First time getting a weight loss injectable altogether.
First time getting a weight loss injectable from Skippack Pharmacy.
I am filling this out for an additional fill (same strength as last month)
I am filling this out for an additional fill (different strength then last month)
I am ordering an oral formulation for the first time.
I am ordering an additional fill of an oral formulation.
Other
Currently, we dispense this medication in VIALS. Would you be interested in receiving it in PRE-FILLED SYRINGES when (key word: WHEN) they become available (same price)? If you select YES, we’ll switch you to pre-filled syringes automatically when we get them. We’re gathering interest to help us decide how many to order.
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PRE-FILLED SYRINGES: I would like to receive the medication in pre-filled syringes when they become available.
VIALS: I prefer to stick with vials.
INDIFFERENT: I am okay with either vials or pre-filled syringes.
Monthly Check-In: How much weight (in lbs) have you lost in the past month?
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Monthly Check-In: HOW DO YOU FEEL after this past month of taking the compounded weight loss medication?
Feel free to share any details you'd like us to know
What is the name of the prescriber who will/has sent/will be sending in the script for you? Please be sure to contact them to get your prescription sent in if it has not already. Due to an overwhelming response, our team will not call the doctor to follow-up to get your prescription for you.
Mailing Address (if Picking Up, Home Address; if Shipping, put address UPS can deliver to)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Submitted
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Month
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Day
Year
Date
Refill Reminder / Feedback Date NOTIFICATION
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Month
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Day
Year
Date
How do you want to receive the medication when ready?
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PICK UP IN PERSON (No additional cost)
SHIP IT TO ME ($30 shipping fee) ***PLEASE MAKE SURE YOU ALSO SELECT "SHIPPING FEE" IN ADDITION TO SELECTING THE MED*** If you don't put a checkmark next to the shipping fee below or see that you've been charged $30 for it at checkout, your order will be delayed/will not ship.
How Many Months Supply Are You Paying For? **Please ensure the provider has send in the correct amount of refills or month's supply for us to cover your request --- if you select multiple months here but pay for a fewer month supply, you will receive what you paid for**
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1-month supply (default is qty: 1 for 1 month's supply)
2-month supply (select qty: 2 for 2 month's supply when selecting the drug below)
3-month supply (select qty: 3 for 3 month's supply when selecting the drug below)
4-month supply (select qty: 4 for 4 month's supply when selecting the drug below)
5-month supply (select qty 5 for 5 month's supply when selecting the drug below)
6-month supply (select qty 6 for 6 month's supply when selecting the drug below)
Which Compounded Formulation Vial Should I Order?
Click the chart below to zoom in
My Products
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Categories:
All
All
GLP-1 Support
Semaglutide Injectables
Tirzepatide Injectables
Oral Semaglutide Formulations
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GLP-1 Support
NOW Vitamin B-12 Lozenges (5,000mcg - 60qty)
Vitamin B12 is essential in staving off anemia, a common concern bariatric patients face due to impaired nutrient absorption. It supports our energy levels and nerve health, making it a critical supplement for anyone on a GLP-1 drug.
$
14.99
NOW Calcium Citrate Caps (120qty)
Calcium citrate is especially beneficial for bariatric patients, offering superior absorption that's not dependent on stomach acid. It plays a key role in preventing bone density loss and osteoporosis, making it a non-negotiable part of our supplement regime. Vitamin D's role in facilitating calcium absorption is vital for maintaining strong, healthy bones and preventing osteoporosis. Given the higher risk of vitamin D deficiency bariatric patients, supplementing with vitamin D is crucial for our bone health and in preventing secondary hyperparathyroidism.
$
16.99
NOW Daily Vits Veg Capsules (120qty)
Multivitamins are a pillar of daily nutritional insurance, filling any gaps in our diet. While they can't replace the rich diversity of a balanced diet, they ensure we're not missing out on essential nutrients, which is especially critical when our nutritional intake falls short.
$
24.99
NOW Probiotic 50 Billion Supplements (50qty)
Introducing probiotics into our regimen helps combat the gastrointestinal side effects of GLP-1 medications, such as nausea and diarrhea, making the treatment more tolerable. Beyond easing these symptoms, probiotics support gut health and may even enhance metabolic health, offering a comprehensive benefit to our weight loss efforts.
$
39.99
NOW Iron 18mg Caps (120qty)
Iron helps the body grow and develop. It also helps the body make hemoglobin in red blood cells, which carry oxygen from the lungs to the body, as well as myoglobin, which provides oxygen to muscles. Iron also makes some hormones.
$
12.99
BD Home Sharps Container 1.5QT
Used to dispose of needles / syringes you use to inject with.
$
7.99
SHIPPING FEE
Please select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.
$
30.00
Semaglutide Injectables
Semaglutide 1 mL - 0.25mg
Same active ingredient as Ozempic or Wegovy 0.25mg
$
179.00
Quantity
1
2
3
4
5
6
Semaglutide 1 mL - 0.50mg
Same active ingredient as Ozempic or Wegovy 0.5mg
$
179.00
Quantity
1
2
3
4
5
6
Semaglutide 2 mL - 0.75mg**
Same active ingredient as Ozempic or Wegovy **0.75mg does not commercially exist as a brand; however, if you have a SLOWER titration, your doc might prescribe this vs moving you up from 0.5mg to 1mg. Most patients will move up from 0.5mg to 1mg**
$
269.00
Quantity
1
2
3
4
5
6
Semaglutide 2 mL - 1mg
Same active ingredient as Ozempic or Wegovy 1mg
$
269.00
Quantity
1
2
3
4
5
6
Semaglutide 3 mL - 1.7mg
Same active ingredient as Wegovy 1.7mg
$
329.00
Quantity
1
2
3
4
5
6
Semaglutide 4 mL (2x2ml vials) - 2mg
Same active ingredient as Ozempic 2mg or Wegovy 2.4mg *you will receive 4ml as 2 x 2ml vials*
$
399.00
Quantity
1
2
3
4
5
6
Semaglutide 4 mL (2x2ml vials) - 2.4mg
Same active ingredient as Ozempic 2mg or Wegovy 2.4mg *you will receive 4ml as 2 x 2ml vials*
$
399.00
Quantity
1
2
3
4
5
6
SHIPPING FEE
Please select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.
$
30.00
Tirzepatide Injectables
Tirzepatide 1 mL - 2.5mg
Same active ingredient as Mounjaro or Zepbound 2.5mg
$
229.00
Quantity
1
2
3
4
5
6
Tirzepatide 2 mL - 5mg
Same active inrgedient as Mounjaro or Zepbound 5mg
$
329.00
Quantity
1
2
3
4
5
6
Tirzepatide 3 mL - 7.5mg
Same active ingredeient as Mounjaro or Zepbound 7.5mg
$
409.00
Quantity
1
2
3
4
5
6
Tirzepatide 4 mL (2x2ml vials) - 10mg
Same active ingredient as Mounjaro or Zepbound 10mg *you will receive 4ml as 2 x 2ml vials*
$
489.00
Quantity
1
2
3
4
5
6
Tirzepatide 5 mL - 12.5mg
Same active ingredient as Mounjaro or Zepbound 12.5mg
$
579.00
Quantity
1
2
3
4
5
6
Tirzepatide 6 mL (2x3ml vials) - 15mg
Same active ingredient as Mounjaro or Zepbound 15mg *you will receive 6ml as 2 x 3ml vials*
$
649.00
Quantity
1
2
3
4
5
6
SHIPPING FEE
Please select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.
$
30.00
Oral Semaglutide Formulations
Semaglutide Capsules 1mg (Qty: 30)
Same active ingredient as Ozempic or Rybelsus, oral capsule form, 1mg
$
229.00
Quantity
1
2
3
Semaglutide Capsules 3mg (Qty: 30)
Same active ingredient as Ozempic or Rybelsus, oral capsule form, 3mg
$
309.00
Quantity
1
2
3
Semaglutide Capsules 6mg (Qty: 30)
Same active ingredient as Ozempic or Rybelsus, oral capsule form, 6mg
$
429.00
Quantity
1
2
3
Semaglutide Capsules 9mg (Qty: 30)
Same active ingredient as Ozempic or Rybelsus, oral capsule form, 9mg
$
549.00
Quantity
1
2
3
Semaglutide + B12 Troches 3mg (Qty: 30)
Same active ingredient as Ozempic or Rybelsus + Vitamin B12, troche form, 3mg
$
309.00
Quantity
1
2
3
Semaglutide + B12 Troches 6mg (Qty: 30)
Same active ingredient as Ozempic or Rybelsus + Vitamin B12, troche form, 6mg
$
429.00
Quantity
1
2
3
Semaglutide + B12 Troches 12mg (Qty: 30)
Same active ingredient as Ozempic or Rybelsus + Vitamin B12, troche form, 12mg
$
669.00
Quantity
1
2
3
Semaglutide Daily Drops, 1 mg/mL, 30 ML
Same active ingredient as Ozempic or Wegovy, daily drop form, 1 mg/mL
$
229.00
Quantity
1
2
3
SHIPPING FEE
Please select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.
$
30.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
**You might wander why this reminder is here---its because many of our patients who want shipping forget to select it & thus delay their order. We value your time and thus put this additional reminder to prevent delays...IF you would like the package shipped to you, please make sure the total above reflects having $30 added to the cost of the item(s) ordered.**
PLEASE CLICK THE EMPTY SQUARE BOX BELOW & THEN SIGN TO ACKNOWLEDGE
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Due to the current shortage of weight loss injectables, Skippack Pharmacy is able to process compounded weight loss medications utilizing a 503A or 503B compounding partner pharmacy. Based on availability & changing FDA guidance, we are able to continue filling these medications; however, the look of your bottle may change based on our fulfillment partners. If you do not see a thank you confirmation on the next page or get an error (Error 1 -- your card is declining, please try reprocessing with another card, Error 2 - our system issue, please email: clinic@skippackpharmacy.com or text 267-766-0076 to inform us so we can fix it on our end), your submission did not go through and payment is not confirmed. Please keep an eye out in your provided email and check your spam email as well from clinic@skippackpharmacy.com. Skippack Pharmacy will NOT provide a refund after the prescription is ordered for any reason. If you agree, please click on the box on the left, sign below and then press the submit button.
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