SEMAGLUTIDE/TIRZEPATIDE PAD

3733 Westheimer Rd. Suite 1-674 Houston, Texas 77027

Ph: +1 (713) 517-7321

All fields marked with * are required and must be filled.

***FAILURE TO PROVIDE PATIENT'S SPECIFIC INFORMATION WILL CAUSE DELAYS***

PATIENT INFORMATION

First Name *

Last Name *

Date of Birth *

Phone Number *

Allergies *

Patient's Specific Address (DO NOT ENTER CLINIC'S ADDRESS) *

Bill to *

Deliver to *

Available Weight Loss Products

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Medical Necessity * (Must have valid documented medical necessity)

Fill box below for: Custom Dosing / Quantity / Comments / Notes / Other Meds

Refills *

Signature or Initials *

Prescriber's Print Name * (ONLY AUTHORIZED PRESCRIBER)

Date *

Clinic Name * (NAME MUST MATCH ACCT SETUP)

Phone Number *

NPI # *

DEA #

Clinic's Address *

E-mail Address for Records Copy *

Please select at least one medication above to continue