Skippack Pharmacy: GLP-1 Continued Interest Form
Skippack Pharmacy GLP-1 Plan
For existing patients, please fill this out to help us better help you.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
E-mail
*
example@example.com
Would you like to continue receiving updates about compounded GLP-1 medications including potential alternatives?
*
Yes
No
How long do you intend to take compounded GLP-1 medications for?
*
1-3 months
3-6 months
6-9 months
9-12 months
1 year+
I am not sure.
Which compounded GLP-1 medication are you on?
*
Injectable: Semaglutide 2.5 mg/mL 1 mL [0.25mg OR 0.5mg]
Injectable: Semaglutide 2.5 mg/mL 2 mL [1mg]
Injectable: Semaglutide 2.5 mg/mL 3 mL [1.7mg]
Injectable: Semaglutide 2.5 mg/mL 4 mL [2mg or 2.4mg]
Injectable: Tirzepatide 10 mg/mL 1 mL [2.5mg]
Injectable: Tirzepatide 10 mg/mL 2 mL [5mg]
Injectable: Tirzepatide 10 mg/mL 3 mL [7.5mg]
Injectable: Tirzepatide 10 mg/mL 4 mL [10mg]
Injectable: Tirzepatide 10 mg/mL 5 mL [12.5mg]
Injectable: Tirzepatide 10 mg/mL 6 mL [15mg]
Oral: Semaglutide 1mg capsules
Oral: Semaglutide 3mg capsules
Oral: Semaglutide 6mg capsules
Oral: Semaglutide 9mg capsules
Oral: Semaglutide and B12(cyanocobalamin) 3mg troches
Oral: Semaglutide and B12(cyanocobalamin) 6mg troches
Oral: Semaglutide and B12(cyanocobalamin) 12mg troches
Oral: Semaglutide 1mg/1ml 30mL-vial oral solution
Will you be discussing a multi-month prescription with your provider?
*
Yes
No
In the near future our compounding partners may be compounding a customized formulation which would have semaglutide or tirzepatide in it in an alternative formulation. We would need a new script with this specific formulation. If your provider would approve, would you be interested in changing over this to this once we run out of our existing supply of what we currently have?
*
Yes
No
I am not sure
Are there any barriers that may prevent you from continuing GLP-1 medications and/or receiving a multi-month prescription?
*
Changing Doses - My doses of compounded GLP-1 change often so tough to get multiple-month supply
Prescription - I do not have a provider or cannot get a multiple-month supply prescribed by my provider
Affordability - I cannot pay for a multiple month supply up front
No Barriers - I am going to ask my prescriber to send in a script for multiple-month supply
Other
If AFFORDABILITY is an issue, would you like us to send you information in the event we come up with an alternative payment plan option for patients who would like multiple months supplies?
*
Yes
No
If PRESCRIPTION is an issue, would you like us to reach out to you/your provider to help?
*
Yes
No
If there are any other barriers, please mention them herein.
Any additional information we should know / anything our team can help you with?
Submit
Should be Empty: