Patient - Semaglutide & Tirzepatide Rx PAD

Semaglutide & Tirzepatide Rx PAD
PATIENT INFORMATION
Patient Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Patient Email Address*
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TRP Account Rep*
If a Texas Regional Physicians representative referred you, please indicate that here.
If other, please indicate below:
Rep Phone Number
Please enter a valid phone number.
PRESCRIPTION
Semaglutide: Injection
*Please note, the 90-day Starter Pack will include:

Shipment 1
Weeks 1-4: Semaglutide 2ml Vial;
Inject 50 units (0.25mg) SQ Weekly

Shipment 2
Weeks 5-8: Semaglutide 2ml Vial;
Inject 50 units (0.5mg) SQ Weekly

Shipment 3
Weeks 9-12: Semaglutide 2ml Vial;
Inject 50 units (1mg) SQ Weekly
Please choose your shipment method for the 90-Day Starter Pack:

Shipment 1 to MD OfficeShipment 1 to Patient AddressShipment 2 to MD OfficeShipment 2 to Patient AddressShipment 3 to MD OfficeShipment 3 to Patient Address
Tirzepatide: Injection
*Please note, the 90-day Starter Pack will include:

Shipment 1
Weeks 1-4: 10mg Tirzepatide - 1mL Vial;
Inject 2.5mg (25 units) SQ weekly

Shipment 2
Weeks 5-8: 20mg Tirzepatide - 2mL Vial;
Inject 5mg (50 units) SQ weekly

Shipment 3
Weeks 9-12: 30mg Tirzepatide - 1.5mL Vial;
Inject 7.5mg (37.5 units) SQ weekly
Please choose your shipment method for the 90-Day Starter Pack:

Shipment 1 to MD OfficeShipment 1 to Patient AddressShipment 2 to MD OfficeShipment 2 to Patient AddressShipment 3 to MD OfficeShipment 3 to Patient Address
PRESCRIPTION UPLOAD

Please upload a copy of the prescription from your physician below:
File Upload*

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Please review that all the information provided above is correct. Our team at Texas Regional Physicians will reach out to you once they receive your prescription and have verified all your information. Please be informed that payment will be collected over the phone and once processed, your medication will be shipped to the address provided.
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Semaglutide & Tirzepatide Rx PAD

PATIENT INFORMATION

PRESCRIPTION

PRESCRIPTION UPLOAD