Physician / Clinic Order Form

Physician / Clinic Order Form
Patient Information (All fields are required for a valid Rx):
Last, First Name*
Gender*
D/O/B*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
E-Mail : (if no e-mail write N/A)
example@example.com
Drug Allergies
Disease CONDITION

YESNO
Disease CONDITION : Diabetic / Pre-Diabetic / Thyroid / Family history of other endocrine,
Rx Healthy Spray Medication Name, Strength & Quantity :
Semaglutide Oral Spray 3 mg/10 ml SIG: Place 1-2 pumps under the tongue, hold for 30 seconds before swallowing twice a day at 5-10 minutes prior to lunch and dinner.*

[ ] THIN (Semaglutide 3 mg/10 ml)[ ] Refills:
[ ] Refills (Not Including above)
THIN is deemed medically necessary by the prescribing practitioner for any of the following reasons (and is not limited to): market alternative has not been identified, patient presented with intolerance of commercially available products, patient is unable to use and/or is strongly averse to market available injectable options, etc.
Physician Information :
Last, First Name*
NPI no.*
Practice Name*
Address*

Address

Street Address Line 2

City/State/ZIPState / Province

Postal / Zip Code
PHONE*
Fax
Email*
example@example.com
Additional Instructions
Provider signature*

Clear
Date*

MonthDayYear
Date
Questions? Contact us at 866-511-8337
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