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Semaglutide & Tirzepatide
Reorder Request

PLEASE NOTE:
If you uncheck the agreement to have your card charged today upon reorder- this will result in a delay in ordering your medication.
You will be contacted separately to ensure we are able to charge your stored card.

If you are wanting to switch medications- you must contact the office prior.

First Name

Last Name

Birthday

Email

Phone Number

Current Dosage

What would you like to do?

Stay at same dosage

Increase dosage

Any new symptoms we should be aware of? If yes, you will be contacted.

Pricing Agreement:

$300 (10-50 units) Semaglutide

$375 (60-70 units) Semaglutide

$450 (80 units) Semaglutide

$500 (90-100 units) Semaglutide

$475 (25 units) Tirzepatide

$525 (50 units) Tirzepatide

$575 (75 units) Tirzepatide

I agree to have my card that is stored on file charged the amount due today.

I would like to be contacted before reorder

No need to contact me, please reorder.

Yes, please call me before reorder.

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