WOMEN'S HEALTH PAYMENT FORM

WOMEN'S HEALTH PAYMENT FORM

Please complete this form to order your women's health medication order. Compounded medications are not covered by insurance and will be available out of pocket. Patients are responsible for the cost of the medication up front. This is NOT a hold on your credit card, by inputting your credit card number below, you will be charged immediately. Please contact us at clinic@skippackpharmacy.com prior to submitting if you have any questions! Once the order is placed through this form, you acknowledge there are no refunds. ***BOOKMARK THIS PAGE: We cannot put your card on file so you will have to fill out a new payment form when you need a refill --> you will use this same payment link for your initial medication & for refills for following months***
RECEIVING YOUR MEDICATION

Based on if you select if you would like it discreetly shipped or picked up in store, you will be notified from our team. If picking up in store, please come to Skippack Pharmacy to pick-up your prescription ONLY AFTER receiving an email or text that it is ready. You do not need to reach out to us --- we will be in touch with you the moment your medication is ready. Our pick-up hours are Mondays-Fridays 10 AM to 7 PM and Saturdays 10AM to 2PM. If you requested for it to be shipped, we will email you with tracking information once the RX is ready.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email [Please be sure to add clinic@skippackpharmacy.com to your contact list as your "Order Ready" email will come from this email address & may end up in spam if not in your contact list]*
**non Comcast.net email preferred as Comcast email addresses have often gone to spam**
Is this your first time ordering injectables/oral formulation or are you getting a refill or additional fill?*

First time getting a women's health medication altogether.First time getting a women's health medication from Skippack Pharmacy.I am filling this out for an additional fill (same medication as last time)I am filling this out for an additional fill (different medication from last time)Other
Check-In: HOW DO YOU FEEL after taking the Women's Health medication?
Feel free to share any details you'd like us to know
What is the NAME OF THE PRESCRIBER who will/has sent/will be sending in the script for you? In case your script did not arrive & you would like us to help you get the script from the provider, PLEASE PROVIDE THE PROVIDER'S PHONE #. If Telehealth and unsure of provider's name, write telehealth company name.*
How do you want to receive the medication when ready?*

PICK UP IN PERSON (No additional cost)SHIP IT TO ME ($30 shipping fee) ***PLEASE MAKE SURE YOU ALSO SELECT "SHIPPING FEE" IN ADDITION TO SELECTING THE MED*** If you don't put a checkmark next to the shipping fee below or see that you've been charged $30 for it at checkout, your order will be delayed.
Mailing Address (if Picking Up, Home Address; if Shipping, put address UPS can deliver to) ***WE CANNOT SHIP TO A PO BOX****

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Submitted

MonthDayYear
Date
Refill Reminder / Feedback Date NOTIFICATION

MonthDayYear
Date
How Many Fills Are You Paying For?*

1 Fill3 Fills5 Fills2 Fills4 Fills6 Fills7 Fills8 Fills9 Fills
Sexual Health: Scream, Climax, or Euphoria Cream? Hair Loss: Minoxidil 2% or ManeTain? Anti-Aging: Injection or Topical?

We've made multiple options available but at the end of the day, the choice is yours. You will need to click the acknowledgement (the next square box) after reading below.
Sexual Health: Each of these creams contain different combinations and strengths of ingredients for varying intensities and results. Scream Cream contains Theophylline 3%, Arginine 6%, and Sildenafil 2%. Scream cream is the lowest potency/intensity available. Climax Cream is the middle ground regarding intensity and contains Theophylline 3%, Arginine 3%, Ergoloid Mesylate 0.05%, and Pentoxifylline 5%. The most potent formulation available is our Euphoria Cream. This product contains Arginine 6%, Papaverine 5%, Alprostadil 0.2%. However, everybody's body is different and some patients may experience different effects compared to other patients.

Hair Loss: The option for hair loss in women is minoxidil 2% solution . Speak with your doctor to see if this is right for you.

Anti-Aging: We have two available options for anti-aging products. This includes NADvantage (topical) and NAD+ injection. It is up to you which product is preferred and it is recommended to speak with your doctor prior to initiating these products to see what is right for you.

**If you've been getting great results, is there a point to switch? That is your choice but if you switch and do not get similar results or have issues, we will not be able to swap out creams**

If unsure which to choose, please speak to your provider. We leave it 100% up to you :)

After selecting what you prefer in the next question, please make sure when you select a product, that the product formulation matches what you would like to receive.

To make it easier we have split the products up in categories based on the drug:
- Sexual Health
  - Scream Cream
  - Climax Cream
  - Euphoria Cream
- Hair Loss
  - Minoxidil 2% solution
  - ManeTain (Minoxidil 5%/Fluocinolone Acetonide 0.01%/Retinoic Acid 0.01%/Vitamin E Acetate 0.5% solution) 100ml spray bottle
- Anti-Aging
  - NADvantage 30g topical
  - NAD+ injection 500mg
Women's Health Options

Click the image below for more information

Please select which medication you are paying for. Ensure it is the right formulation. *

Sexual Health

Scream Cream 30g PumpUse as directed

$100.00 Quantity

Climax Cream 30g PumpUse as directed

$130.00 Quantity

Euphoria Cream 30g PumpUse as directed

$100.00 Quantity

SHIPPING FEEPlease select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.

$30.00

Hair Loss

Minoxidil 2% topical solutionUse as directed (one month supply 60mL bottle)

$37.99 Quantity

$30.00

Anti-Aging

NADvantageUse as directed (Nicotinamide Adenine Dinucleotide 10%) 30g Cream

$142.00 Quantity

NAD+ Injection 500mg vial 50mg/mLUse as directed: Includes Bacteriostatic Water and 10mL mixing syringe

$238.04 Quantity

$30.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

**You might wonder why this reminder is here---its because many of our patients who want shipping forget to select it & thus delay their order. We value your time and thus put this additional reminder to prevent delays...IF you would like the package shipped to you, please make sure the total above reflects having $30 added to the cost of the item(s) ordered.**
PLEASE CLICK THE EMPTY SQUARE BOX BELOW & THEN SIGN TO ACKNOWLEDGE*

If you do not see a thank you confirmation on the next page or get an error (Error 1 -- your card is declining, please try reprocessing with another card, Error 2 - our system issue, please email: clinic@skippackpharmacy.com or text 267-766-0076 to inform us so we can fix it on our end), your submission did not go through and payment is not confirmed. Please keep an eye out in your provided email and check your spam email as well from clinic@skippackpharmacy.com. Skippack Pharmacy will NOT provide a refund after the prescription is ordered for any reason. If you agree, please click on the box on the left, sign below and then press the submit button. ONCE THE PRODUCT LEAVES OUR PHARMACY (PICKED UP OR SHIPPED TO YOU), THERE ARE NO REFUNDS.
Signature*

Clear
Date

MonthDayYear
Date
Refill Notification Date

MonthDayYear
Date
Should be Empty:

WOMEN'S HEALTH PAYMENT FORM

RECEIVING YOUR MEDICATION

Sexual Health: Scream, Climax, or Euphoria Cream? Hair Loss: Minoxidil 2% or ManeTain? Anti-Aging: Injection or Topical?

Women's Health Options

Payment Methods