Semaglutide & Tirzepatide Rx PAD
PATIENT INFORMATION
Patient Name
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Phone Number
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Patient Shipping Address
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Street Address
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State / Province
Postal / Zip Code
TRP Account Rep
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Amanda
Clarissa
Devin
Victoria
00723
41042
Other
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Rep Phone Number
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BILLED TO TEXAS REGIONAL PHYSICIANS ON BEHALF OF MD OFFICE
8301 Katy Freeway, Suite #101 - Houston, TX 77024 - Keith Sparenberg (832) 474-2079
Deliver to
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MD OFFICE
PATIENT
PRESCRIPTION
Semaglutide: Injection
Please Select
Month 1 - Semaglutide 0.25mg/0.5ml, Week 1-4
Month 2 - Semaglutide 0.5mg/0.5ml, Week 5-8
Month 3 - Semaglutide 1mg/0.5ml, Week 9-12
FOLLOW-UP - Semaglutide 1.7mg/0.5ml, Week 13-16
FOLLOW-UP -Semaglutide 2.4mg/0.5ml, Week 17
90 Day Starter Pack (Sent in 30 day increments)
Tirzepatide: Injection
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Month 1 - 10mg Tirzepatide in a 1mL Vial, Week 1-4
Month 2 - 20mg Tirzepatide in a 2mL Vial, Week 5-8
Month 3 - 30mg Tirzepatide in a 1.5mL Vial, Week 9-12
FOLLOW-UP - 40mg Tirzepatide in a 2mL Vial, Week 13-16
60mg Tirzepatide in a 3mL Vial, Week 17-20
60mg Tirzepatide in a 3mL Vial, Week 20 and onwards
90 Day Starter Pack (Sent in 30 day increments)
PHYSICIAN INFORMATION
Provider Name
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Signature
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Clinic Phone:
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Date
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Month
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Day
Year
Date
Clinic Address
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Street Address
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State / Province
Postal / Zip Code
NPI
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Supervising MD (if applicable):
NPI
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