Provider Prescription Provider name * Email * Medication * SelectSemaglutide 0.25mgSemaglutide 0.5mgSemaglutide 1mgSemaglutide 1.7mgSemaglutide 2.4mgTirzepatide 2.5mgTirzepatide 5mgTirzepatide 7.5mgTirzepatide 10mgTirzepatide 12.5mgTirzepatide 15mgOther Medication Only one medication can be added at a time Prescription Repeater (DEPRECATED) Medication Type SelectGeneral MedicationCompounding Medication Medication Name Please add one medication at a time. Use the “Add more” button below the form to add more prescription Describe Quantity Prescription Click Here to Upload Your Prescription Choose File Maximum file size: 10MB plus1 Add more minus1 Remove If you are human, leave this field blank. Next Δ
