Weight loss intake form

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.

The Medicine Shoppe, Shillington PA, has received all approvals during this back-order period and has developed program for an Injectable Semaglutide and Terzepatide (Mounjaro and Zepbound) with the same active ingredients as Wegovy and Ozempic.

Cost:

o Injectable: Starting at $300 every 4 weeks

NEED A DOCTOR?: Visit Physician360 or call (360) 861-6199 to get a prescription for weight loss meds via telemedicine ($59.95).

The Medicine Shoppe is not directly partnered with or affiliated with Physician 360; however, it provides referrals to assist patients in need of a provider. We have had patients successfully utilize their service, and we can refer you for a consultation.

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, 7 days in advance to go over your progress and prepare the next month's dosage.

NEED A DOCTOR?:

Visit Physician360 or call (360) 861-6199 to get a prescription for weight loss meds via telemedicine ($59.95).

The Medicine Shoppe is not directly partnered with or affiliated with Physician 360.
However, it provides referrals to assist patients in need of a provider.
We have had patients successfully utilize their service.
We can refer you for a consultation.
This is very useful if your primary care is not willing to prescribe you a weight loss medication.
The cost for visit is $59.95.

Patient's Name*

First NameLast Name

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Cell Phone Number*

Email*

example@example.com

Please provide the name and city of the Doctor/Provider who prescribes this medication for you*

If never been on this type of medication, then please provide your primary care prescriber name.

Please indicate a few dates and times a specialist can reach-out to answer any questions and process?*

How did you hear about us?*

Which medication do you have a current prescription for?

Please select the compounded product that matches your CURRENT prescription (see table above)

Any other information you would like to add?

I understand and acknowledge that I will have my prescriber send a script to The Medicine Shoppe, Shillington PA, only if I am informed to do so. I understand and acknowledge that The Medicine Shoppe, Shillington PA, can and will advocate on your behalf and have a clinical conversation with the prescriber. The Medicine Shoppe, Shillington PA, will not be able to dispense medication without a valid prescription.

DATE

Date