WeightPath MD
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NC
NovoCare Pharmacy
WeightPath MD form (Wegovy) - fax 1-833-947-0246
LV
LillyDirect - Zepbound Vial
Official Lilly vial form - fax 1-833-541-1760
LK
LillyDirect Zepbound KwikPen
Official Lilly KwikPen form - fax 1-833-541-1760
FO
LillyDirect - Foundayo Oral
Official Lilly form (orforglipron tablets) - fax 1-833-541-1760
AZ
Amazon Pharmacy
WeightPath MD form - fax 512-884-5981
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Patient
Full name (First MI Last)
Date of birth
Mobile phone
Gender
Street address
City
State
Zip
Email (optional)
Address (street, city, state, zip)
Allergies
Medication
Product
Dose
Medication & strength
Quantity
Days supply
Refills
Sig (directions)
Dispense as written (DAW)
Medication
One strength per form. Quantity is fixed at 4 single-dose vials / 28 days by the form.
Zepbound vial dose
Refills
Medication
One strength per form. Quantity is fixed at 1 bottle of 30 tablets / 30 days by the form.
Foundayo once-daily tablet dose
Refills
Medication
One strength per form. Quantity is fixed at one KwikPen (four weekly injections) / 28 days by the form.
Zepbound KwikPen dose (weekly)
Refills
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