PAYMENT FORM-Compounded Semaglutide/Tirzepatide

WEIGHT LOSS INJECTABLE/ORAL FORMULATION PAYMENT FORM

Please complete this form to order your compounded semaglutide or tirzepatide prescription for pick up at Skippack Pharmacy. This product is not covered by insurance and will be available out of pocket. Patients are responsible for the cost of the medication up front. This is NOT a hold on your credit card, by inputting your credit card number below, you will be charged immediately. Please contact us at clinic@skippackpharmacy.com prior to submitting if you have any questions! Once the order is placed through this form, you acknowledge there are no refunds. ***BOOKMARK THIS PAGE: We cannot put your card on file so you will have to fill out a new payment form when you need a refill --> you will use this same payment link for your initial medication & for refills for following months***
RECEIVING YOUR MEDICATION

Based on if you select if you would like it shipped or pick up in store, you will be notified from our team. If picking up in store, please come to Skippack Pharmacy to pick-up your prescription ONLY AFTER receiving an email or text that it is ready. You do not need to reach out to us --- we will be in touch with you the moment your medication is ready. Our pick-up hours are Mondays-Fridays 10 AM to 7 PM and Saturdays 10AM to 2PM. If you requested for it to be shipped, we will email you with tracking information once the RX is ready.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email [Please be sure to add clinic@skippackpharmacy.com to your contact list as your "Order Ready" email will come from this email address & may end up in spam if not in your contact list]*
**non Comcast.net email preferred as Comcast email addresses have often gone to spam**
Is this your first time ordering injectables/oral formulation or are you getting a refill or additional fill?*

First time getting a weight loss injectable altogether.First time getting a weight loss injectable from Skippack Pharmacy.I am filling this out for an additional fill (same strength as last month)I am filling this out for an additional fill (different strength then last month)I am ordering an oral formulation for the first time.I am ordering an additional fill of an oral formulation.Other
Monthly Check-In: How much weight (in lbs) have you lost in the past month? If you would not like to share this info just hit next.
Monthly Check-In: HOW DO YOU FEEL after this past month of taking the compounded weight loss medication?
Feel free to share any details you'd like us to know
What is the NAME OF THE PRESCRIBER who will/has sent/will be sending in the script for you? In case your script did not arrive & you would like us to help you get the script from the provider, PLEASE PROVIDE THE PROVIDER'S PHONE #. If Telehealth and unsure of provider's name, write telehealth company name.*
How do you want to receive the medication when ready?*

PICK UP IN PERSON (No additional cost)SHIP IT TO ME ($30 shipping fee) ***PLEASE MAKE SURE YOU ALSO SELECT "SHIPPING FEE" IN ADDITION TO SELECTING THE MED*** If you don't put a checkmark next to the shipping fee below or see that you've been charged $30 for it at checkout, your order will be delayed.
Mailing Address (if Picking Up, Home Address; if Shipping, put address UPS can deliver to) ***WE CANNOT SHIP TO A PO BOX****

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Submitted

MonthDayYear
Date
Refill Reminder / Feedback Date NOTIFICATION

MonthDayYear
Date
How can I ensure I have enough medication to transition when the shortage ends. Should I order a multiple month supply now?

YES, if your provider decides that is best for you.
How Many Months Supply Are You Paying For? **Please ensure the provider has send in the correct amount of refills or month's supply for us to cover your request - we can only fill what they send in a prescription for** For multiple month supply, we recommend you select vial IF you think your prescriber may change your dose over time as vials allow for more flexible titration (adjustment) of doses. Pre-filled syringes come with a set amount which cannot be modified. There are no returns/refunds on any unused product once it leaves the pharmacy.*

1-month supply2-month supply3-month supply4-month supply5-month supply6-month supply7-month supply8-month supply9-month supply
How Would You Like To Receive The Medication?*

VIAL - I'd like to receive the medication in a vial where I can draw up my own doses. You will still receive empty syringes to draw up from the vial.SYRINGE (pre-filled) - I'd like to receive the medication in a 4 pack of pre-filled syringes.ORAL - I am getting Capsules, Drops, or Troches.
Vials or Syringes?

We've made multiple options available but at the end of the day, the choice is yours. You will need to click the acknowledgement (the next square box) after reading below.
If you have been taking the medication from the vial, its worked, and you do not find it difficult to draw out of a vial, the choice to switch to pre-filled syringe is yours OR you can stick with vials for the refill.

**If you've been getting great results, is there a point to switch? That is your choice but if you switch and do not get similar results or have issues, we will not be able to swap out vials for pre-filled syringes or pre-filled syringes for vials**

The active ingredient (main ingredient) in both formulations (vials and pre-filled syringes) is the same but the inactive ingredients differ slightly. Please look at the graphic below if you want to see the similarities vs differences of both formulations.

If unsure which to choose, please speak to your provider. We leave it 100% up to you :)

After selecting what you prefer in the next question, please make sure when you select a product, that the product formulation matches what you would like to receive.

To make it easier we have split the products up in categories based on the drug:

Semaglutide VIALS
Semaglutide PRE-FILLED SYRINGES
Tirzepatide VIALS
Tirzepatide PRE-FILLED SYRINGES
Oral Semaglutide Formulations
GLP-1 Support
Vial Conversion Chart

Click the chart below to zoom in

Please select which medication you are paying for. Ensure it is the right formulation (vials, pre-filled syringes, capsules, drops, troches). *

Semaglutide VIALS

Semaglutide 1 mL - 0.25mg VIAL

$179.00 Quantity

Semaglutide 1 mL - 0.375mg** VIAL**0.375mg does not commercially exist as a brand; however, if you have a SLOWER titration, your doc might prescribe this vs moving you up from 0.25mg to 0.5mg. Most patients will move up from 0.25mg to 0.5mg**. DO NOT SELECT THIS OPTION UNLESS YOU ARE SURE.

$179.00 Quantity

Semaglutide 1 mL - 0.50mg VIAL

$179.00 Quantity

Semaglutide 2 mL - 1mg VIAL

$269.00 Quantity

Semaglutide 2 mL - 0.75mg** VIAL**0.75mg does not commercially exist as a brand; however, if you have a SLOWER titration, your doc might prescribe this vs moving you up from 0.5mg to 1mg. Most patients will move up from 0.5mg to 1mg**. DO NOT SELECT THIS OPTION UNLESS YOU ARE SURE.

$269.00 Quantity

Semaglutide 3 mL - 1.7mg VIAL

$329.00 Quantity

Semaglutide 4 mL (2x2ml vials) - 2mg VIAL

$399.00 Quantity

Semaglutide 4 mL (2x2ml vials) - 2.4mg VIAL

$399.00 Quantity

SHIPPING FEEPlease select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.

$30.00

Semaglutide PRE-FILLED SYRINGES

Semaglutide 0.25mg pre-filled SYRINGE (4pk)

$179.00 Quantity

Semaglutide 0.5mg pre-filled SYRINGE (4pk)

$179.00 Quantity

Semaglutide 1mg pre-filled SYRINGE (4pk)

$269.00 Quantity

Semaglutide 1.7mg pre-filled SYRINGE (4pk)

$329.00 Quantity

Semaglutide 2.4mg pre-filled SYRINGE (4pk)

$399.00 Quantity

$30.00

Tirzepatide VIALS

Tirzepatide 1 mL - 2.5mg VIAL

$229.00 Quantity

Tirzepatide 2 mL - 5mg VIAL

$329.00 Quantity

Tirzepatide 3 mL - 7.5mg VIAL

$409.00 Quantity

Tirzepatide 4 mL (2x2ml vials) - 10mg VIAL

$489.00 Quantity

Tirzepatide 5 mL - 12.5mg VIAL

$579.00 Quantity

Tirzepatide 6 mL (2x3ml vials) - 15mg VIAL

$649.00 Quantity

$30.00

Tirzepatide PRE-FILLED SYRINGES

Tirzepatide 2.5mg pre-filled SYRINGE (4pk)

$229.00 Quantity

Tirzepatide 5mg pre-filled SYRINGE (4pk)

$329.00 Quantity

Tirzepatide 7.5mg pre-filled SYRINGE (4pk)

$409.00 Quantity

Tirzepatide 10mg pre-filled SYRINGE (4pk)

$489.00 Quantity

Tirzepatide 12.5mg pre-filled SYRINGE (4pk)

$579.00 Quantity

Tirzepatide 15mg pre-filled SYRINGE (4pk)

$649.00 Quantity

$30.00

Oral Semaglutide Formulations

Semaglutide Capsules 1mg (Qty: 30)

$229.00 Quantity

Semaglutide Capsules 3mg (Qty: 30)

$309.00 Quantity

Semaglutide Capsules 6mg (Qty: 30)

$429.00 Quantity

Semaglutide Capsules 9mg (Qty: 30)

$549.00 Quantity

Semaglutide + B12 Troches 3mg (Qty: 30)

$309.00 Quantity

Semaglutide + B12 Troches 6mg (Qty: 30)

$429.00 Quantity

Semaglutide + B12 Troches 12mg (Qty: 30)

$669.00 Quantity

Semaglutide Daily Drops, 1 mg/mL, 30 ML

$229.00 Quantity

$30.00

GLP-1 Support

NOW Vitamin B-12 Lozenges (5,000mcg - 60qty)Vitamin B12 is essential in staving off anemia, a common concern bariatric patients face due to impaired nutrient absorption. It supports our energy levels and nerve health, making it a critical supplement for anyone on a GLP-1 drug.

$14.99 Quantity

NOW Calcium Citrate Caps (120qty)Calcium citrate is especially beneficial for bariatric patients, offering superior absorption that's not dependent on stomach acid. It plays a key role in preventing bone density loss and osteoporosis, making it a non-negotiable part of our supplement regime. Vitamin D's role in facilitating calcium absorption is vital for maintaining strong, healthy bones and preventing osteoporosis. Given the higher risk of vitamin D deficiency bariatric patients, supplementing with vitamin D is crucial for our bone health and in preventing secondary hyperparathyroidism.

$16.99 Quantity

NOW Daily Vits Veg Capsules (120qty)Multivitamins are a pillar of daily nutritional insurance, filling any gaps in our diet. While they can't replace the rich diversity of a balanced diet, they ensure we're not missing out on essential nutrients, which is especially critical when our nutritional intake falls short.

$24.99 Quantity

NOW Probiotic 50 Billion Supplements (50qty)Introducing probiotics into our regimen helps combat the gastrointestinal side effects of GLP-1 medications, such as nausea and diarrhea, making the treatment more tolerable. Beyond easing these symptoms, probiotics support gut health and may even enhance metabolic health, offering a comprehensive benefit to our weight loss efforts.

$39.99 Quantity

NOW Iron 18mg Caps (120qty)Iron helps the body grow and develop. It also helps the body make hemoglobin in red blood cells, which carry oxygen from the lungs to the body, as well as myoglobin, which provides oxygen to muscles. Iron also makes some hormones.

$12.99 Quantity

Ondansetron 4mg ODT (RX Anti-Nausea Med)IF your prescriber is sending in an RX for ondansetron 4mg ODT (which many of our patients have used as RX-strength anti-nausea medication), please select this option. If you are unsure, do not select it & we'll send you a link after.

$20.00 Quantity

BD Home Sharps Container 1.5QTUsed to dispose of needles / syringes you use to inject with.

$7.99 Quantity

$30.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

**You might wonder why this reminder is here---its because many of our patients who want shipping forget to select it & thus delay their order. We value your time and thus put this additional reminder to prevent delays...IF you would like the package shipped to you, please make sure the total above reflects having $30 added to the cost of the item(s) ordered.**
PLEASE CLICK THE EMPTY SQUARE BOX BELOW & THEN SIGN TO ACKNOWLEDGE*

Due to the current shortage of weight loss injectables, Skippack Pharmacy is able to process compounded weight loss medications utilizing a 503A or 503B compounding partner pharmacy. Based on availability & changing FDA guidance, we are able to continue filling these medications; however, the look of your bottle may change based on our fulfillment partners. If you do not see a thank you confirmation on the next page or get an error (Error 1 -- your card is declining, please try reprocessing with another card, Error 2 - our system issue, please email: clinic@skippackpharmacy.com or text 267-766-0076 to inform us so we can fix it on our end), your submission did not go through and payment is not confirmed. Please keep an eye out in your provided email and check your spam email as well from clinic@skippackpharmacy.com. Skippack Pharmacy will NOT provide a refund after the prescription is ordered for any reason. If you agree, please click on the box on the left, sign below and then press the submit button. ONCE THE PRODUCT LEAVES OUR PHARMACY (PICKED UP OR SHIPPED TO YOU), THERE ARE NO REFUNDS.
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WEIGHT LOSS INJECTABLE/ORAL FORMULATION PAYMENT FORM

RECEIVING YOUR MEDICATION

Vials or Syringes?

Vial Conversion Chart

Payment Methods