Semaglutide Product Purchase Order Form

Semaglutide 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
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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. Note: Expiration Date is November 26, 2026. No extended expiration is available.

$90.00

Dose	Quantity	Price
1.0mg		$90.00
2.4mg		$75.00

Total

Payment Options.
Provider Notes
Authorized Signature
Date

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2 digit month, 2 digit day, 4 digit yearDate
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Semaglutide Office Use Order Form

My Products