WOMEN'S HEALTH PAYMENT FORM

WOMEN'S HEALTH PAYMENT FORM

Place your women’s health medication order below.Compounded medications are cash pay only, and your card will be charged immediately upon submission. Please bookmark this page for future refills, as this same form will be used each time and we cannot store cards on file All orders are final and non-refundable.Questions: clinic@skippackpharmacy.com
RECEIVING YOUR MEDICATION

Our team will notify you based on your selected delivery method.Pickup: Please wait for your ready email/text before coming to the pharmacy.Hours: Mon–Fri 10–6 | Sat 10–2Discreet shipping: Tracking details will be emailed once your prescription ships.
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**
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.*
PICK UP IN PERSON (No additional cost)SHIP IT TO ME ($10 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 $10 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
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.

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

Sexual Health

Scream Cream 30g Pump

Use as directed

$100.00 Quantity

Climax Cream 30g Pump

Use as directed

$130.00 Quantity

Euphoria Cream 30g Pump

Use as directed

$100.00 Quantity

SHIPPING FEE

Please select this option if you would like the medication shipped to you.

$10.00

Hair Loss

Minoxidil 2% topical solution

Use as directed (one month supply 60mL bottle)

$37.99 Quantity

SHIPPING FEE

Please select this option if you would like the medication shipped to you.

$10.00

Anti-Aging

NADvantage

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

$142.00 Quantity

NAD+ Injection 500mg vial 50mg/mL

Use as directed: Includes Bacteriostatic Water and 10mL mixing syringe

$238.04 Quantity

SHIPPING FEE

Please select this option if you would like the medication shipped to you.

$10.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

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?

Payment Methods