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SummitRxPharmacy.com | P: 816-524-8444 | 1405 NE Douglas | Lee's Summit, MO
Semaglutide Interest Form
First Name
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Last Name
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Date of Birth
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Mobile Phone Number
(Home number if no mobile number)
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Street Address
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City
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State
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Zip Code
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Email Address
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Confirm Email Address
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Primary Care Provider (If Applicable)
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Are you currently taking a product for weight loss?
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No
Yes, Semaglutide/Ozempic
Yes, Semaglutide/Wegovy
Yes, Tirepatide/Mounjaro
Yes, Phentermine
In the past 30 days have you taken a product for weight loss?
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No
Yes, Semaglutide/Ozempic
Yes, Semaglutide/Wegovy
Yes, Tirepatide/Mounjaro
Yes, Phentermine
If you answered YES to either question above, what is the most recent strength you have taken?
Please select the preferred route of administration
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Weekly Injections
Daily drops administered under the tongue
How did you hear about us?
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Current Patient
Facebook
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Physician
Other
By typing my name below:
I am agreeing to periodic communication via telephone, text message, or email from Summit Rx Pharmacy.
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Compounded medications are not reviewed by the FDA for safety or efficacy.