Product Purchase Order Form

Tirzepatide Office Use Order Form

RX Valet LLC, Greenville, SC Phone: 855-798-2538
CLINIC DETAILS *
Contact Name*

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email*
example@example.com

My Products

Medivant Semaglutide Prefilled Syringes. Price: PLUS SHIPPING COSTS

Quantity: Each box contains 4 prefilled syringes. Minimum 5 boxes. NOTE: Prices include Credit Card Charges. SHIPPING COSTS ARE EXTRA AND WILL BE APPLIED BASED UPON LOCATION AND QUANTITY.

$90.00

Dose	Quantity	Price
1.0mg		$90.00
2.4mg		$75.00

Total

$0.00

Pay via credit/debit card
Provider Notes
Authorized Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Tirzepatide Office Use Order Form