Compounded Semaglutide/Tirzepatide Form
Through the years, our pharmacy has been a pillar for our community when things are on shortage. We heard about this shortage & have come up with a solution to help. Skippack Pharmacy is now proud to be offering a compounded form of semaglutide and tirzepatide to our patients. This is the same active ingredient found in the FDA branded weight loss products but at an out of pocket cost (off of your insurance). This form will ask you a few questions regarding your medication, history, and basic demographics. You will only have to fill this out ONCE (not for any refills or future script).
Let's learn a little more about you.
We may know some of you, we may not know others but we'd love to know everyone who we have the opportunity to serve & thus need some information to get you started.
Patient status with Skippack Pharmacy
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I have used Skippack Pharmacy for prescriptions
I have used Skippack Pharmacy for vaccines or testing
I am new to Skippack Pharmacy
Who is filling out this form?
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I am filling this out for myself
I am filling this out for my spouse, significant other, family member
I am filling this out for my patient.
Patient's Name
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First Name
Last Name
How Did You Hear About Us / This Program?
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Instagram (Ad/Post)
Facebook (Ad/Post)
Google (Ad/Post)
A News Website (NP Now, PV Now, Wiss Now)
My Doctor
A Friend / Family Member
I Am A Patient of Skippack Pharmacy
Other
Any Additional Detail on the Referral Source? (name of person, provider, etc.) Leave blank if none.
Gender
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Female
Male
Other
Current Height
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Current Weight
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Date of Birth
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Month
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Day
Year
Date Picker Icon
Patient Address (if you will be requesting the product be shipped to you, please ensure the address below is your mailing address)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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Please double check and ensure this is accurate
Cell Phone Number
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Area Code
Phone Number
Please list any allergies to medications.
If none, leave blank & move on to the next question.
Do you have a provider who you can get a prescription from?
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Yes, I have a provider (doctor, physician assistant, nurse practitioner, etc.) who will prescribe this medication for me.
No, I do not but I would like to connect with a telehealth provider to get a script. Skippack Pharmacy cannot prescribe; however has worked with telehealth providers like Physician 360 who we can refer you to.
Please list the name and city of the DOCTOR/PROVIDER who may prescribe this medication for you (if you will be using a telehealth provider & not sure, write TELEHEALTH)
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Please list any other medications you may be taking.
If none, leave blank & move on to the next question.
Please list any current medical conditions.
If none, leave blank & move on to the next question.
Select below IF you have any of the following medical history? If YES, please ensure the provider who is writing your prescription is aware of this. If NONE, skip to next question.
Family/personal history of medullary thyroid carcinoma
History of pancreatitis
History of GI Diseases
Known hypersensitivity to tirzepatide or semaglutide
Prior weight loss surgeries
Family or personal history of Multiple Endocrine Neoplasia Type 2
Have or have had problems with your pancreas or kidneys
Have a history of diabetic retinopathy
Are pregnant or breastfeeding or plan to become pregnant or breastfeed
Let's get to know you a little more.
The best part about choosing a local pharmacy is that you get to speak to someone you can trust, someone you can reach out to with any issues, someone who wants to see succeed in your goals to better health. **If you don't feel comfortable sharing this information - no problem at all, skip to the next section** The sole purpose to collect this information is to allow us to provide you better service and help you along your journey!
What is your weight loss goal?
Lose 1-20 lbs for good
Lose 21-50 lbs for good
Lose over 50 lbs for good
Maintain my weight and get fit
Haven't decided
Other
What goals are you trying to accomplish?
Lose weight
Improve general health
Look better
Improve confidence
Increase energy
Other
What have you tried in the past?
Exercise
Dieting
Weight loss supplements
Intermittent fasting
Weight loss programs
Weight loss injectables
Other
Let's talk about the medication.
The best part about choosing a local pharmacy is that you get to speak to someone you can trust, someone you can reach out to with any issues, someone who wants to see succeed in your goals to better health. This information will allow us to provide you better service and help you along your journey!
Which medication are you looking for the compounded formulation of?
Ozempic
Wegovy
Mounjaro
Zepbound
Rybelsus
I am not sure
Other
What strength of this medication are you looking for?
If not sure, put UNKNOWN
What are the current directions of this medication?
If not sure, put UNKNOWN
What weight loss formulation are you interested in?
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Injectable [Most Common, about 95% of our patients]
Oral [Less Common, about 5% of our patients]
Please select the INJECTABLE product that matches the prescription you are seeking
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Injectable: Semaglutide 2.5 mg/mL 1 mL (same active ingredient as Ozempic or Wegovy 0.25 or 0.5mg)
Injectable: Semaglutide 2.5 mg/mL 2 mL (same active ingredient as Ozempic or Wegovy 1mg)
Injectable: Semaglutide 2.5 mg/mL 3 mL (same active ingredient as Wegovy 1.7mg)
Injectable: Semaglutide 2.5 mg/mL 4 mL (same active ingredient as Ozempic 2mg or Wegovy 2.4mg)
Injectable: Tirzepatide 10 mg/mL 1 mL (same active ingredient as Mounjaro or Zepbound 2.5mg)
Injectable: Tirzepatide 10 mg/mL 2 mL (same active ingredient as Mounjaro or Zepbound 5mg)
Injectable: Tirzepatide 10 mg/mL 3 mL (same active ingredient as Mounjaro or Zepbound 7.5mg)
Injectable: Tirzepatide 10 mg/mL 4 mL (same active ingredient as Mounjaro or Zepbound 10mg)
Injectable: Tirzepatide 10 mg/mL 5 mL (same active ingredient as Mounjaro or Zepbound 12.5mg)
Injectable: Tirzepatide 10 mg/mL 6 mL (same active ingredient as Mounjaro or Zepbound 15mg)
I am not sure about what medication or strength I am supposed to take - I don't have a script but will speak to the provider about this.
Please select the ORAL product that matches the prescription you are seeking
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Oral: Semaglutide 1mg capsules (same active ingredient as Rybelsus and Ozempic)
Oral: Semaglutide 3mg capsules (same active ingredient as Rybelsus and Ozempic)
Oral: Semaglutide 6mg capsules (same active ingredient as Rybelsus and Ozempic)
Oral: Semaglutide 9mg capsules (same active ingredient as Rybelsus and Ozempic)
Oral: Semaglutide and B12(cyanocobalamin) 3mg troches (same active ingredient as Rybelsus and Ozempic)
Oral: Semaglutide and B12(cyanocobalamin) 6mg troches (same active ingredient as Rybelsus Ozempic)
Oral: Semaglutide and B12(cyanocobalamin) 12mg troches (same active ingredient as Rybelsus and Ozempic)
Oral: Semaglutide 1mg/1ml 30mL-vial oral solution (same active ingredient as Rybelsus and Ozempic)
I am not sure about what medication or strength I am supposed to take - I don't have a script but will speak to the provider about this.
Please list the name and city of your CURRENT PHARMACY
If none, leave blank & move on to the next question.
At this time, compounded semaglutide & tirzepatide is not covered by insurance. Are you willing to pay OUT OF POCKET (can use HSA card, credit card, etc.) price is dose dependent and ranges from $179.00 to $649.00 per month supply based on the medication type and amount? Prices are transparent, there are no hidden fees, and are the prices listed in the table above.
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Yes
No, I would only like this medication processed through insurance (Do not move forward as unfortunately, we cannot process compounded weight loss medications through insurance).
How would you like to receive the medication once it is ready? You can change your mind and update this when you fill out the payment form.
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Pick up in person - no additional charge
Ship to me - +$30 shipping fee
How many months supply would you be interested in getting at once? You can change your mind and update this when you fill out the payment form.
1-month
2-month
3-month
I'm not sure.
Have you taken any self-injectable before? I.e. Insulin, allergy shots, weight loss injectable, fertility, etc.
Yes, it was pre-filled syringes
Yes, it was from a vial
No, this is my first time
N/A, I am interested in an oral formulation
Any other information you would like to add to help us help you?
If nothing, leave blank & move on to the last line.
I understand and acknowledge that by filling out this form, I authorize Skippack Pharmacy to provide me with next steps. I will receive an email or click the link on the thank you page for next steps and will move forward with the directions provided therein. I also understand that this product cannot be processed through my insurance & am okay paying out of pocket for it.
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Submit
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