PAYMENT FORM-Compounded Semaglutide/Tirzepatide

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*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email **non Comcast.net email preferred as Comcast email addresses have often gone to spam***
example@example.com
Is this your first time ordering injectables/oral formulation or are you getting a refill or additional fill?*

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.*

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?*
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.
Shipping Address (if Picking Up, Home Address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Submitted

MonthDayYear
Date
Refill Reminder / Feedback Date NOTIFICATION

MonthDayYear
Date
How do you want to receive the medication when ready?*

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***

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*

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 1.5QTUsed to dispose of needles / syringes you use to inject with.

$7.99

SHIPPING FEEPlease select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Thursday via UPS. By selecting this you, agree with our shipping disclaimer.

$30.00

Semaglutide Injectables

Semaglutide 1 mL - 0.25mgSame active ingredient as Ozempic or Wegovy 0.25mg

$179.00 Quantity

Semaglutide 1 mL - 0.50mgSame active ingredient as Ozempic or Wegovy 0.5mg

$179.00 Quantity

Semaglutide 2 mL - 0.75mgSame active ingredient as Ozempic or Wegovy 0.75mg

$269.00 Quantity

Semaglutide 2 mL - 1mgSame active ingredient as Ozempic or Wegovy 1mg

$269.00 Quantity

Semaglutide 3 mL - 1.7mgSame active ingredient as Wegovy 1.7mg

$329.00 Quantity

Semaglutide 4 mL (2x2ml vials) - 2mgSame active ingredient as Ozempic 2mg or Wegovy 2.4mg *you will receive 4ml as 2 x 2ml vials*

$399.00 Quantity

Semaglutide 4 mL (2x2ml vials) - 2.4mgSame active ingredient as Ozempic 2mg or Wegovy 2.4mg *you will receive 4ml as 2 x 2ml vials*

$399.00 Quantity

SHIPPING FEEPlease select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Thursday via UPS. By selecting this you, agree with our shipping disclaimer.

$30.00

Tirzepatide Injectables

Tirzepatide 1 mL - 2.5mgSame active ingredient as Mounjaro or Zepbound 2.5mg

$229.00 Quantity

Tirzepatide 2 mL - 5mgSame active inrgedient as Mounjaro or Zepbound 5mg

$329.00 Quantity

Tirzepatide 3 mL - 7.5mgSame active ingredeient as Mounjaro or Zepbound 7.5mg

$409.00 Quantity

Tirzepatide 4 mL (2x2ml vials) - 10mgSame active ingredient as Mounjaro or Zepbound 10mg *you will receive 4ml as 2 x 2ml vials*

$489.00 Quantity

Tirzepatide 5 mL - 12.5mgSame active ingredient as Mounjaro or Zepbound 12.5mg

$579.00 Quantity

Tirzepatide 6 mL (2x3ml vials) - 15mgSame active ingredient as Mounjaro or Zepbound 15mg *you will receive 6ml as 2 x 3ml vials*

$649.00 Quantity

SHIPPING FEEPlease select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Thursday via UPS. 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

Semaglutide Capsules 3mg (Qty: 30)Same active ingredient as Ozempic or Rybelsus, oral capsule form, 3mg

$309.00 Quantity

Semaglutide Capsules 6mg (Qty: 30)Same active ingredient as Ozempic or Rybelsus, oral capsule form, 6mg

$429.00 Quantity

Semaglutide Capsules 9mg (Qty: 30)Same active ingredient as Ozempic or Rybelsus, oral capsule form, 9mg

$549.00 Quantity

Semaglutide + B12 Troches 3mg (Qty: 30)Same active ingredient as Ozempic or Rybelsus + Vitamin B12, troche form, 3mg

$309.00 Quantity

Semaglutide + B12 Troches 6mg (Qty: 30)Same active ingredient as Ozempic or Rybelsus + Vitamin B12, troche form, 6mg

$429.00 Quantity

Semaglutide + B12 Troches 12mg (Qty: 30)Same active ingredient as Ozempic or Rybelsus + Vitamin B12, troche form, 12mg

$669.00 Quantity

Semaglutide Daily Drops, 1 mg/mL, 30 MLSame active ingredient as Ozempic or Wegovy, daily drop form, 1 mg/mL

$229.00 Quantity

SHIPPING FEEPlease select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Thursday via UPS. By selecting this you, agree with our shipping disclaimer.

$30.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

**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. This is one last 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.**
SHIPPING DISCLAIMER:

The medication is shipped in an insulated cold package and are shipped from Skippack Pharmacy Monday-Thursday using UPS overnight (if shipped on a Friday, we'll add extra ice packs). The ice packs are frozen when they leave our pharmacy & will melt by the time they reach you. The vial should not be hot but can be room temperature upon arrival. If left outside of refrigeration the injections are still good for 30 days with the same potency and stability. You will receive tracking information via email so you are aware where the package is.

Skippack Pharmacy is not responsible in the event your package is dropped off to your home and you are away from your house on vacation, work, etc.

THE PACKAGE IS DELIVERED TO THE ADDRESS YOU HAVE LISTED ABOVE --- IF YOU ARE NOT HOME, IT WILL BE LEFT OUTSIDE YOUR HOME WITH A PHOTO TAKEN.

If the package comes unsealed, damaged, or with any contents missing, please take photos IMMEDIATELY (within 12 hours of receiving) & email them to our team at clinic@skippackpharmacy.com, text 267-766-0076, call 610-584-7937. UPS will also require these photos when filing a claim.

To ensure accuracy, our pharmacy uses cameras when packaging & shipping and thus will go back to review footage if any issues. Once delivered, outside of 12 hours, we are not responsible for any potential issues.

Please do not select "SHIP IT TO ME" unless you agree with the above.
PLEASE CLICK THE EMPTY SQUARE BOX BELOW & THEN SIGN TO ACKNOWLEDGE*

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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WEIGHT LOSS INJECTABLE/ORAL FORMULATION PAYMENT FORM

RECEIVING YOUR MEDICATION

Which Compounded Formulation Vial Should I Order?

Payment Methods