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SEMAGLUTIDE/TIRZEPATIDE PAD

123 Medical Plaza Drive, Suite 200, Springfield, IL 62701

Ph: (555) 123-4567 | Fax: (555) 765-4321

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 *

PRESCRIPTION

New Compound

Reach out to your representative for more info.

Liraglutide/Pyridoxine 15mg-4mg/0.5mL (3mL 90mg Vial) $280.00

●Week 1: Inject 0.6mg subcutaneously once a day
●Week 2: Inject 1.2mg subcutaneously once a day
●Week 3: Inject 1.8mg subcutaneously once a day
●Week 4: Inject 2.4mg subcutaneously once a day
●Week 5: Inject 3mg subcutaneously once a day
●Maintenance Dose: 3mg subcutaneously once a day

Semaglutide

Semaglutide Vial Options

Semaglutide/Pyridoxine 1mg-8mg/mL (1mL)

1mg vial

Semaglutide/Pyridoxine 2mg-8mg/mL (1mL)

2mg vial

Semaglutide/Pyridoxine 4mg-8mg/mL (1mL)

4mg vial

Semaglutide/Pyridoxine 4mg-8mg/mL (2mL)

8mg vial

Semaglutide/Pyridoxine 5mg-8mg/mL (2mL)

10mg vial

12 Week Special Supply - Semaglutide/Pyridoxine 2.5mg-8mg/mL (5mL)

12.5mg vial

(Dispensed as #3 2mL VIALS - 30mg) - Semaglutide/Pyridoxine 5mg-8mg/mL

Semaglutide/B6 Sublingual Rapid Dissolving Tablets

Semaglutide/Pyridoxine 0.6mg-10mg RDT (8 Week Supply - 40 Tabs) $280.00

Sig: Dissolve 1 tablet under the tongue twice weekly for Weeks 1 and 2, then dissolve 2 tablets under the tongue twice weekly (Weeks 3 and 4), then dissolve 3 tablets under the tongue twice weekly (Weeks 5 and 6), then dissolve 4 tablets under the tongue twice weekly (Weeks 7 and 8)

Semaglutide/B6 3.6mg-10mg RDT (4 Week Supply) $225.00

Sig: Dissolve 1 tablet under the tongue twice weekly for 4 weeks

Tirzepatide

Tirzepatide Vial Options

Tirzepatide/pyridoxine 10mg-8mg/mL (1mL)

10mg vial

Tirzepatide/pyridoxine 10mg-4mg/0.5mL (1mL)

20mg vial

Tirzepatide/pyridoxine 10mg-8mg/mL (3mL)

30mg vial

Tirzepatide/pyridoxine 10mg-4mg/0.5mL (2mL)

40mg vial

Tirzepatide/pyridoxine 15mg-4mg/0.5mL (2mL)

60mg vial

Tirzepatide/pyridoxine 10mg-4mg/0.5mL (6mL)

120mg vial

(Dispensed as #3 2mL Vials - 180mg) - Tirzepatide/pyridoxine 15mg-4mg/0.5mL

Tirzepatide/Semaglutide 20mg/2mg/mL (2mL 40mg/4mg MDV) $335.00

Tirzepatide/Semaglutide 2mg/0.2mg

= 10 units SQ weekly

Tirzepatide/Semaglutide 4mg/0.4mg

= 20 units SQ weekly

Tirzepatide/Semaglutide 6mg/0.6mg

= 30 units SQ weekly

Tirzepatide/Semaglutide 8mg/0.8mg

= 40 units SQ weekly

Tirzepatide/Semaglutide 10mg/1mg

= 50 units SQ weekly

Tirzepatide/Semaglutide 30mg/5mg/mL (2mL 60mg/10mg MDV) $405.00

Tirzepatide/Semaglutide 3mg/0.5mg

= 10 units SQ weekly

Tirzepatide/Semaglutide 6mg/1mg

= 20 units SQ weekly

Tirzepatide/Semaglutide 9mg/1.5mg

= 30 units SQ weekly

Tirzepatide/Semaglutide 12mg/2mg

= 40 units SQ weekly

Tirzepatide/Semaglutide 13.2mg/2.2mg

= 44 units SQ weekly

Medical Necessity * (Must have valid documented medical necessity)

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

Commonly Prescribed Together

Cagrilintide 5mg/mL MDV (2mL -10mg vial)

Lipo-Trim MDV 10mL

Lipo-Trim MDV 30mL

Zofran 4mg (ODT)

($1.00/ODT) Minimum 10 Tabs

Tesofensine 500mcg Caps

#30 $280.00 / #60 $450.00 / #90 $600.00

Refills *

PHYSICIAN INFORMATION

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 *

Compounding • Wellness • Patient-Centric Care

info@medconnetrx.com

3733 Westheimer Rd 1-674

Houston Texas 77027

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