Semaglutide PerfectRX

Semaglutide Program

Practice Information
Practice Name*
Practice Administrator:*

First NameLast Name
Medical Director Name:*

First NameLast Name
NPI: *
Practice Address:*

Street Address

sdfghj

CityState / Province

Postal / Zip Code
Billing Address if Different:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Credit Authorization
I, as the cardholder, hereby authorize PerfectRX/Smartscripts Pharmacy to charge my credit card for Medications/Semaglutide and confirm that the information for the credit card and billing address is complete and accurate.

I have been informed that I can cancel the recurring payment at least 15 days before the payment by phone or signing a consent form provided by the merchant company.
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Semaglutide Program