Weight Loss & HRT Premier Order Form

Prescription Order Form

12827 Telge Rd Ste 160, Cypress, TX 77429 Phone (281) 654-8417, Fax (281) 605-1912 compounding@AGEritePharmacy.com www.AGEritePharmacy.com
Weight Loss & HRT - Compounded Medications

FOR CLINIC USE
Patient's Information

*MUST BE LEGITIMATE PATIENT SPECIFIC INFORMATION*
Patient Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Medication Allergies
Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PROTOCOL DOSING INFORMATION

TIRZEPATIDE

SEMAGLUTIDE

New Protocol:

WEEK 1-4: Inject 2.5mg SQ weekly
WEEK 5-8 : Inject 5mg SQ weekly
WEEK 9-12: Inject 7.5mg SQ weekly

New Protocol:

WEEK 1-4: Inject 0.25mg SQ weekly
WEEK 5-8 : Inject 0.5mg SQ weekly
WEEK 9-12: Inject 1.0mg SQ weekly

Second Protocol:

WEEK 13-16: Inject 10mg SQ weekly
WEEK 17-20: Inject 12.5mg SQ weekly
WEEK 21-24: Inject 15mg SQ weekly

Second Protocol:

WEEK 13-16: Inject 1.5mg SQ weekly
WEEK 17-20: Inject 2.0mg SQ weekly
WEEK 21-24: Inject 2.5mg SQ weekly

Maintenance:

Inject 15mg SQ weekly x 12 weeks

Maintenance:

Inject 2.5mg SQ weekly x 12 weeks

SEMAGLUTIDE/B12 Multi-Dose Vials - FIXED Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost.
Please choose from below and state quantity for each
SEMAGLUTIDE/B12 Multi-Dose Vials - CUSTOM Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost. Concentration of cyanocolabalmin in all vials is 1000mcg/mL.
Please choose from below and state quantity for each
SEMAGLUTIDE/GLYCINE Multi-Dose Vials - FIXED Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost. Concentration of Glycine included in vials is 2.5mg/mL
Please choose from below and state quantity for each
SEMAGLUTIDE/GLYCINE Multi-Dose Vials - CUSTOM Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost. Concentration of Glycine included in vials is 2.5mg/mL
Please choose from below and state quantity for each
TIRZEPATIDE/B3 Multi-Dose Vials - FIXED Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost. Concentration of B3 in all vials is 2mg/mL.
Please choose from below and state quantity for each
TIRZEPATIDE/B3 Multi-Dose Vials - CUSTOM Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost. Concentration of B3 in all vials is 2mg/mL.
Please choose from below and state quantity for each
TIRZEPATIDE/GLYCINE Multi-Dose Vials - FIXED Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost. Concentration of Glycine included in vials is 2.5mg/mL
Please choose from below and state quantity for each
TIRZEPATIDE/GLYCINE Multi-Dose Vials - CUSTOM Dosing

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost. Concentration of Glycine included in vials is 2.5mg/mL
Please choose from below and state quantity for each
SEMAGLUTIDE Pre-Filled Syringes (4-week supply)

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost.
Please choose one below:
TIRZEPATIDE Pre-Filled Syringes (4-week supply)

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost.
Please choose one below:
Hormone Replacement Therapy

Delivery costs $15 per order. Supplies included in cost.
Please choose one below:
Dose
SIG
Quantity
Number of Refills
Is this prescription for use by the patient at home?
Include injection supplies for no additional charge? (Note: This is only provided for patient use at home.)

Other
Prescriber's Information
Prescriber's Name

First NameLast Name
Prescriber Email Address
example@example.com
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number for order update texts
Please enter a valid phone number. Type N/A if no text updates wantedFormat: (000) 000-0000.
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescriber License
Prescriber Credentials
MD, DO, PA, FNP, etc.
Prescriber NPI
Prescriber DEA
Required to prescribe controlled substances
Prescriber Signature
*I certify this is the authorizing prescriber signature*
I certify that this prescription is medically necessary for this patient.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Delivery Information & Turnaround Times
Shipping
- Standard turnaround time: 1-3 business days from receipt of the prescription to delivery.
- Prescriptions received by 12 PM on a business day will be shipped the same day via next day shipping on ice.
- Shipping is free for orders over $250. Orders less than $250 will be charged a $20 shipping fee
- Prescriptions received after 2pm on Thursday will be shipped out on Monday.
Local Houston-Area Delivery
- For local orders, prescriptions received by 12 PM will be delivered the next business day.
- Prescriptions received after 12 PM will be delivered within up to 2 business days.
Large Orders (3 or more vials)
- Prescription orders received and payments processed by 2 PM on a business day will be delivered in 3 business days
Business Hours (subject to change)
- Monday: 10 AM - 3 PM
- Tuesday: 11 AM - 4 PM
- Wednesday 10 AM - 3 PM
- Thursday: 10 AM - 3 PM
- Friday: 10 AM - 3 PM
- Saturday: Closed
- Sunday: Closed
Delivery Option
Shipping Speed - orders shipped Mon-Thurs
Delivery Address
Responsible party for payment
Does patient want signature requirement waived for delivery?
Product needed by

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you are working with an Account Executive, please list their name:
Comments/ Notes to Pharmacy
PAYMENT INFORMATION
Would you like to enter payment info?
Should be Empty:

Prescription Order Form

Weight Loss & HRT - Compounded Medications

Patient's Information

SEMAGLUTIDE/B12 Multi-Dose Vials - FIXED Dosing

SEMAGLUTIDE/B12 Multi-Dose Vials - CUSTOM Dosing

SEMAGLUTIDE/GLYCINE Multi-Dose Vials - FIXED Dosing

SEMAGLUTIDE/GLYCINE Multi-Dose Vials - CUSTOM Dosing

TIRZEPATIDE/B3 Multi-Dose Vials - FIXED Dosing

TIRZEPATIDE/B3 Multi-Dose Vials - CUSTOM Dosing

TIRZEPATIDE/GLYCINE Multi-Dose Vials - FIXED Dosing

TIRZEPATIDE/GLYCINE Multi-Dose Vials - CUSTOM Dosing

SEMAGLUTIDE Pre-Filled Syringes (4-week supply)

TIRZEPATIDE Pre-Filled Syringes (4-week supply)

Hormone Replacement Therapy

Prescriber's Information

Delivery Information & Turnaround Times

PAYMENT INFORMATION