little Acorn Pharmacy - Oral SL Semaglutide Order Form

11161 New Hampshire Ave Ste 110 Silver Spring, MD 20904 · P: 301-592-0060 · F: 301-592-0054
SEMAGLUTIDE CAPSULES

At little Acorn Pharmacy, we prioritize the highest quality standards for our medications, ensuring trust and reliability in your healthcare. Our Oral Semaglutide, tested rigorously by an independent lab, guarantees efficacy and safety with a shelf-life of 180 days.
- The pharmacy will process the order once all necessary information is provided.
- Payment is due before compounding. We will contact the patient for payment and delivery information
- Prescription orders require verification with the prescribing doctor.
- Insurance coverage is not offered on compounding
- The medication expires after 180 days.
- Free shipping for Maryland and Washington, DC
- Questions? Text us at 301.780.4645 or call us at 301.592.0060.
Today's Date*

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Patient Information
Name*

First NameLast Name
Date of Birth*

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Date
Phone Number*
Please enter a valid phone number.
Patient Email*
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Shipping Address*

Street Address

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Postal / Zip Code
Prescription Information
Prescriber's Name*

First NameLast Name
Prescriber's Email*
example@example.com
Semaglutide enteric coated capsules
what strength?

2.5 MG Capsules $249 (30)5 MG Capsules $329 (30)
Directions*

Default Directions - Take 1 capsule by mouth daily in the morning on an empty stomachCustom Directions
Quantity*
Refills (months)*

0123456
NPI Number*
Delivery/Pickup Preference*

DeliveryIn-Store pickupI don't know (Contact Patient)
Prescriber's Signature*

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The FDA does not review any compounded medication from any pharmacy for safety or efficacy. Rybelsus ® is a registered trademark of Novo Nordisk A/S.
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11161 New Hampshire Ave Ste 110 Silver Spring, MD 20904 · P: 301-592-0060 · F: 301-592-0054

SEMAGLUTIDE CAPSULES

Patient Information

Prescription Information

Semaglutide enteric coated capsules