Weight Loss 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 - 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
Date
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
SEMAGLUTIDE/B12 Multi-Dose Vials

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost.
Semaglutide/B12 2.5mg/mL - 1000mcg/mL 1mL MDV (2.5mg total) - $70Semaglutide/B12 2.5mg/mL - 1000mcg/mL 2mL MDV (5mg total) - $100Semaglutide/B12 2.5mg/mL - 1000mcg/mL 3mL MDV (7.5mg total) - $110Semaglutide/B12 2.5mg/mL - 1000mcg/mL 4mL MDV (10mg total) - $120Semaglutide/B12 2.5mg/mL - 1000mcg/mL 5mL MDV (12.5mg total) - $150Semaglutide/B12 5mg/mL - 1000mcg/mL 1mL MDV (5mg total) - $100Semaglutide/B12 5mg/mL - 1000mcg/mL 2mL MDV (10mg total) - $120Semaglutide/B12 5mg/mL - 1000mcg/mL 3mL MDV (15mg total) - $150Semaglutide/B12 5mg/mL - 1000mcg/mL 4mL MDV (20mg total) - $180Semaglutide/B12 5mg/mL - 1000mcg/mL 5mL MDV (25mg total) - $200
SEMAGLUTIDE/GLYCINE Multi-Dose Vials

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost.
Semaglutide/Glycine 2.5mg/mL - 2.5mg/mL 1mL MDV (2.5mg total) - $70Semaglutide/Glycine 2.5mg/mL - 2.5mg/mL 2mL MDV (5mg total) - $100Semaglutide/Glycine 2.5mg/mL - 2.5mg/mL 3mL MDV (7.5mg total) - $110Semaglutide/Glycine 2.5mg/mL - 2.5mg/mL 4mL MDV (10mg total) - $120Semaglutide/Glycine 2.5mg/mL - 2.5mg/mL 5mL MDV (12.5mg total) - $150Semaglutide/Glycine 5mg/mL - 2.5mg/mL 1mL MDV (5mg total) - $100Semaglutide/Glycine 5mg/mL - 2.5mg/mL 2mL MDV (10mg total) - $120Semaglutide/Glycine 5mg/mL - 2.5mg/mL 3mL MDV (15mg total) - $150Semaglutide/Glycine 5mg/mL - 2.5mg/mL 4mL MDV (20mg total) - $180Semaglutide/Glycine 5mg/mL - 2.5mg/mL 5mL MDV (25mg total) - $200
TIRZEPATIDE/B3 Multi-Dose Vials

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost.
Tirzepatide/B3 10mg/mL - 2mg/mL 1mL MDV (10mg total) - $80Tirzepatide/B3 10mg/mL - 2mg/mL 2mL MDV (20mg total) - $100Tirzepatide/B3 10mg/mL - 2mg/mL 3mL MDV (30mg total) - $180Tirzepatide/B3 10mg/mL - 2mg/mL 4mL MDV (40mg total) - $200Tirzepatide/B3 10mg/mL - 2mg/mL 5mL MDV (50mg total) - $275Tirzepatide/B3 25mg/mL - 2mg/mL 1mL MDV (25mg total) - $150Tirzepatide/B3 25mg/mL - 2mg/mL 2mL MDV (50mg total) - $275Tirzepatide/B3 25mg/mL - 2mg/mL 3mL MDV (75mg total) - $375Tirzepatide/B3 25mg/mL - 2mg/mL 4mL MDV (100mg total) - $499Tirzepatide/B3 25mg/mL - 2mg/mL 5mL MDV (125mg total) - $599Tirzepatide/B3 25mg/mL - 2mg/mL 8mL MDV (175mg total) - $800
TIRZEPATIDE/GLYCINE Multi-Dose Vials

Our Beyond-Use Dating for our batches is 90 days. Pricing is per multidose vial. Shipping is included in the cost.
Tirzepatide/Glycine 10mg/mL - 2mg/mL 1mL MDV (10mg total) - $80Tirzepatide/Glycine 10mg/mL - 2mg/mL 2mL MDV (20mg total) - $100Tirzepatide/Glycine 10mg/mL - 2mg/mL 3mL MDV (30mg total) - $180Tirzepatide/Glycine 10mg/mL - 2mg/mL 4mL MDV (40mg total) - $200Tirzepatide/Glycine 10mg/mL - 2mg/mL 5mL MDV (50mg total) - $275Tirzepatide/Glycine 25mg/mL - 2mg/mL 1mL MDV (25mg total) - $150Tirzepatide/Glycine 25mg/mL - 2mg/mL 2mL MDV (50mg total) - $275Tirzepatide/Glycine 25mg/mL - 2mg/mL 3mL MDV (75mg total) - $375Tirzepatide/Glycine 25mg/mL - 2mg/mL 4mL MDV (100mg total) - $499Tirzepatide/Glycine 25mg/mL - 2mg/mL 5mL MDV (125mg total) - $599Tirzepatide/Glycine 25mg/mL - 2mg/mL 8mL MDV (175mg total) - $800
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.
Semaglutide/B12 0.25 mg prefilled syringes - Inject 0.25mg SQ every week for 4 weeks - $85Semaglutide/B12 0.5 mg prefilled syringes - Inject 0.5 mg SQ every week for 4 weeks - $95Semaglutide/B12 0.75 mg prefilled syringes - Inject 0.75 mg SQ every week for 4 weeks - $100Semaglutide/B12 1 mg prefilled syringes - Inject 1 mg SQ every week for 4 weeks - $105Semaglutide/B12 1.5 mg prefilled syringes - Inject 1.5 mg SQ every week for 4 weeks - $125Semaglutide/B12 1.75 mg prefilled syringes - Inject 1.75 mg SQ every week for 4 weeks - $130Semaglutide/B12 2 mg prefilled syringes - Inject 2 mg SQ every week for 4 weeks - $135Semaglutide/B12 2.5 mg prefilled syringes - Inject 2.5mg SQ every week for 4 weeks - $150
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.
Tirzepatide/B3 2.5 mg prefilled syringes - Inject 2.5 mg SQ every week for 4 weeks - $135Tirzepatide/B3 5 mg prefilled syringes - Inject 5 mg SQ every week for 4 weeks - $220Tirzepatide/B3 7.5 mg prefilled syringes - Inject 7.5 mg SQ every week for 4 weeks - $260Tirzepatide/B3 10 mg prefilled syringes - Inject 10 mg SQ every week for 4 weeks - $290Tirzepatide/B3 12.5 mg prefilled syringes - Inject 12.5 mg SQ every week for 4 weeks - $320Tirzepatide/B3 15 mg prefilled syringes - Inject 15 mg SQ every week for 4 weeks - $350
Dose*
SIG*
Quantity*
Number of Refills*
YesNoOther
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 Signature*

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*I certify this is the authorizing prescriber signature*
I agree
Date*

MonthDayYear
Date
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*
Delivery Address*
Product needed by*

MonthDayYear
Date
If you are working with an Account Executive, please list their name:
Comments/ Notes to Pharmacy
PAYMENT INFORMATION
YesNoUse payment info on file for prescriber
Should be Empty:

Prescription Order Form

Weight Loss - Compounded Medications

Patient's Information

SEMAGLUTIDE/B12 Multi-Dose Vials

SEMAGLUTIDE/GLYCINE Multi-Dose Vials

TIRZEPATIDE/B3 Multi-Dose Vials

TIRZEPATIDE/GLYCINE Multi-Dose Vials

SEMAGLUTIDE Pre-Filled Syringes (4-week supply)

TIRZEPATIDE Pre-Filled Syringes (4-week supply)

Prescriber's Information

Delivery Information & Turnaround Times

PAYMENT INFORMATION