Compounded GLP-1 Step 1 of 5 20% COMPOUNDED GLP-1 SEMAGLUTIDE / TIRZEPATIDE (WEIGHT LOSS MEDICATIONS)Through the years, Hayden’s Pharmacy has been a pillar for the neighborhoods that we serve! It is our dedication to our patients and determination to be a true full service pharmacy, we are now providing a solution to the GLP-1 drug shortage and lack of insurance formulary coverage. Our solution is simple – We are offering compounded GLP-1 medications to allow patients to achieve new goals and live healthier lives! HOW WE CAN DO THIS The compounded GLP-1 products contain the same active ingredients found in the FDA branded weight loss products. This products are prepared in a sterile laboratory environment, prepared with accuracy and compounding certification assays performed to ensure its absolute correctness. The compounded GLP-1 products are offered as CASH PRICE (Out of pocket cost). This compounded item is NOT billable to insurance. This form will ask you a few questions regarding your medication, history, and basic demographics. Once you are registered for our COMPOUNDED GLP-1 program, you will be able to proceed with our process. BEFORE WE START THE COMPOUNDED GLP-1 REGISTRATION PROCESS:, By continuing, you agree: 1) You are 18 years old or older or the legal guardian of the patient. 2) The information provided is accurate to the best of your ability. 3) You completely understand pages forthcoming will be shared with our medical provider team and compounding pharmacists to find you the best options.By selecting "I Agree" below, you also have read and accept Hayden’s Pharmacy Compounding Services Terms of Use.(Required) I Agree.Standard email is not a secure means of communication and your protected health information that may be contained in our emails to you will not be encrypted. This means that there is risk that your protected health information in the emails could be intercepted and read by, or disclosed to, unauthorized third parties. You accept the risks associated with a non-secure unencrypted email communications from us containing your protected health information. COMPOUNDED GLP-1 SEMAGLUTIDE / TIRZEPATIDE PRE SCREENING FORM PLEASE ENTER THE FOLLOWING:Patient Name:(Required) First Last Patient Gender:(Required) Male Female Patient Date of Birth:(Required) MM slash DD slash YYYY Patient Race:(Required)Select One:CaucasianBlack or African AmericanOtherPatient Ethnicity:(Required)Select One:Not Hispanic or LatinoHispanic or LatinoPatient Address:(Required) Street Address Apartment, Suite, or Floor City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please tell us about your allergies and/or medication allergies that you might have:Please select any of the following medical conditions that you currently have: tell us about your allergies and/or medication allergies that you might have:(Required) Cancer (Any Form) Chronic Lung Disease (Asthma / Emphysema) Diabetes Heart Condition (Heart Attack / Stroke / Heart Failure) High Blood Pressure High Cholesterol / High LDL Immunocompromised (including Cancer Treatment, Immune Deficiencies, Organ Transplant, Use of Corticosteroids) Kidney Disease Liver Disease Neurological Disorder Not Applicable Please enter the patient's current HEIGHT ('FT "IN):Please enter the patient's current WEIGHT (LBS):CONTACT INFORMATION:Patient Email:(Required) Enter Email Confirm Email Patient Phone Number:(Required)Confirm Phone Number:(Required) PLEASE TELL US MORE ABOUT YOU SO WE CAN EXPEDITE THIS PROCESS:Please select the best answer that describes you:(Required) I am a current patient at Hayden’s Pharmacy for my prescription needs. I have used Hayden’s Pharmacy for my vaccine and/or testing services. I am NEW patient for Hayden’s Pharmacy. Do you ALREADY have a prescription for a GLP-1 medication from your personal primary care physician?(Required) Yes No PLEASE UPLOAD YOUR GLP-1 PRESCRIPTION HERE:(Required)Max. file size: 50 MB.SINCE YOU AS THE PATIENT DO NOT CURRENTLY HAVE A PRESCRIPTION FOR A GLP-1, WE ARE MORE THAN HAPPY TO CONNECT YOU WITH OUR TELEDOC MEDICAL PROVIDER TO CONDUCT YOUR EVALUATION AND ISSUE THE MOST APPROPRIATE COMPOUNDED GLP-1 PRESCRIPTION FOR YOU! PLEASE SELECT THE GLP-1 PRODUCT FROM OUR OPTIONS AVAILABLE:(Required)Semeglutide 0.25mg/ 0.05ml (PREFILLED SYRINGE) Equivalent to Ozempic/Wegovy 0.25mgSemeglutide 0.5mg/ 0.1ml (PREFILLED SYRINGE) Equivalent to Ozempic/Wegovy 0.5mgSemeglutide 1.0mg/ 0.2ml (PREFILLED SYRINGE) Equivalent to Ozempic/Wegovy 1.0mgSemeglutide 1.7mg/ 0.22ml (PREFILLED SYRINGE) Equivalent to Wegovy 1.7mgSemeglutide 2.4mg/ 0.3ml (PREFILLED SYRINGE) Equivalent to Wegovy 2.4mgTirzepatide 2.5mg/ 0.1ml (PREFILLED SYRINGE) Equivalent to Mounjaro/Zepbound 2.5mgTirzepatide 5mg/ 0.2ml (PREFILLED SYRINGE) Equivalent to Mounjaro/Zepbound 5mgTirzepatide 7.5mg/ 0.3ml (PREFILLED SYRINGE) Equivalent to Mounjaro/Zepbound 7.5mgTirzepatide 10mg/ 0.2ml (PREFILLED SYRINGE) Equivalent to Mounjaro/Zepbound 10mgTirzepatide 12.5mg/ 0.25ml (PREFILLED SYRINGE) Equivalent to Mounjaro 12.5mgTirzepatide 15mg/ 0.3ml (PREFILLED SYRINGE) Equivalent to Mounjaro 15mgSemeglutide 1mg/1ml (VIAL & SYRINGE) Equivalent to Ozempic/Wegovy 0.25mgSemeglutide 2.5mg/1ml (VIAL & SYRINGE) Equivalent to Ozempic/Wegovy 0.5mgSemeglutide 5mg/2ml (VIAL & SYRINGE) Equivalent to Ozempic/Wegovy 1mgSemeglutide 10mg/4ml (VIAL & SYRINGE) Equivalent to Ozempic/Wegovy 2mgDELIVERY OF YOUR COMPOUNDED GLP-1 PRESCRIPTION:(Required) I will be picking up my prescription at Hayden’s Pharmacy, 505 North Fourth Street, Youngwood, PA. I would like this item shipped VIA USPS to my address listed. TOTAL: PAYMENT:(Required) By selecting "I Agree" below, granting permission to Hayden's Pharmacy to charge my credit card for services rendered. I Agree.CAPTCHA