Name *

First Name

Last Name

Cell Phone Number *

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I agree to receiving notifications via text. Payment is due prior to us ordering your products. We will text (325-669-2808) and coordinate payment either via card, venmo, or cash app. All you will have to do is pick up product from Mister Meds Pharmacy (141 Clyde Street Abilene, TX) between 9 AM-5:00 PM once they notify you that your prescription is ready. *

Agree

What vial are you interested in?

Semaglutide 1 mg Vial ($225 card/$200 venmo)

Semaglutide 2.5 mg Vial ($350 card/$325 venmo)

Semaglutide 5 mg Vial ($500 card/$475 venmo)

Semaglutide 10 mg Vial ($750 card/$725 venmo)

Tirzepatide 20 mg Vial ($425 card/$400 venmo)

Tirzepatide 40 mg Vial ($625 card/$600 venmo)

Tirzepatide 60 mg Vial ($850 card/$825 venmo)

Tirzepatide 100 mg Vial ($1200 card/$1175 venmo)

Do you have history of pancreatitis? (if yes, you are not a candidate for semaglutide/tirzepatide) *

Yes

No

Do you have active gallbladder problems such as gallstones? (if yes, you are not a candidate for semaglutide/tirzepatide) *

Yes

No

Do you or your immediate family (mom/dad) have a history of thyroid cancer? (if yes, you are not a candidate for semaglutide/tirzepatide) *

Yes

No

Are you pregnant or planning to become pregnant in the next two months? (Discontinue immediately if pregnancy occurs while on this medication as it can increase risk of birth defects) *

Yes

No

BUNDLE & SAVE $50 off these common peptides

One month supply of the following:

AOD/NAD Troche ($175)

AOD/CJC/Ipamoreline Troche ($175)

Sermoreline/Ipamoreline/Theanine Troche ($175

BUNDLE & SAVE $25: Would you like to add some NAD+ Injections to your order? NAD+ can help aid in weight loss, energy levels, mental clarity, and even has anti-aging properties

NAD 200 mg/1ml ($60)

NAD 600 mg/3ml ($200)

All Sales Are Final *

We do not accept refunds on wellness products or weight loss injections. These items are custom-compounded and cannot be returned or resold. Please ensure you are committed before placing your order.

Agree

Legal Stuff: Client Privacy Rights. Terms and Conditions: https://docs.google.com/document/d/1lXGSUu3HkHxTQ57BZ5U60n-HWUFEMQhUf4xCT4nJSD8/edit?usp=sharing *

I have read and agree to the terms above