Tirzepatide Order Form -

For new and established weight loss patients. Please complete all required fields and review your dose carefully before submitting.

Submissions are sent directly to Dr. Thomas’s clinical team via secure email. Please do not include credit card numbers or other payment details in this form.

Patient Name

First

Last

DOB

Patient Phone Number

Patient Email Address

Are you a New patient?

If you are a followup patient, when did you start Tirzepatide?

If a followup patient, what was your starting weight?

Follow up Patient and New patients: What is Your Current Weight?

Follow up patients: What Tirzepatide dose are you currently taking?

If you have been off Tirzepatide for more than 5 weeks, you will need to start at 2.5mg or 5mg.

Follow up patients: Any side effects with taking the Tirzepatide?

Follow up patients: Have you started any new supplements or prescription medicines since your last refill? If yes, list them below.

Check the box of any current supplements that you are taking?

What type of exercises are you doing?

How many calories do you eat daily?

How many meals do you eat daily?

Women only: Is there a chance that you can be pregnant?

Women only: Are you breastfeeding?

Have you had labs drawn within 12 months?

Follow up patients: What Dose do you want to order today?

DO NOT ATTEMPT TO SKIP DOSES, THIS WILL INCREASE YOUR PRICE TO $100 PER WEEK, INSTEAD OF THE DISCOUNTED PRICES.

How many vials do you want to order today?

Follow up patients: When (date) did you take your last injection?

DO YOU KNOW WHAT PHARMACY YOUR LAST INJECTIONS CAME FROM?

New Patients: Choose a starting Pharmacy

Follow up Patients: Choose a Follow up Vial to Purchase

Medicine will be shipped to your home. Click pharmacy shipping method.

Address to ship medicine to.

Additional Message (Optional)

Acknowledgment

I CONFIRM THE INFORMATION ABOVE IS ACCURATE AND I AM THE PATIENT PLACING THIS ORDER. I UNDERSTAND SURE SUCCESS WELLNESS CENTER IS NOT RESPONSIBLE FOR LOST OR DAMAGED PACKAGES ONCE TRACKING HAS BEEN ISSUED.

medicines LAST current

Signature (type full name)

Today's Date and Time of Request

Date

Time