Enter full name, date of birth, and dosing for each (1 to 4) patient(s)
Provider name
Provider email
Full Name (Patient 1)
Date of Birth (Patient 1)
GLP-1 and Dose (Patient 1) Please Select SEMA - 1mg SEMA - 2mg SEMA - 4mg SEMA - 6.8mg SEMA - 10mg SEMA - 25mg TIRZ - 10mg TIRZ - 20mg TIRZ - 30mg TIRZ - 40mg TIRZ - 50mg TIRZ - 60mg
Specific Dosing instructions (Patient 1)
Full Name (Patient 2)
Date of Birth (Patient 2)
GLP-1 and Dose (Patient 2) Please Select SEMA - 1mg SEMA - 2mg SEMA - 4mg SEMA - 6.8mg SEMA - 10mg SEMA - 25mg TIRZ - 10mg TIRZ - 20mg TIRZ - 30mg TIRZ - 40mg TIRZ - 50mg TIRZ - 60mg
Specific Dosing Instructions (Patient 2)
Full Name (Patient 3)
Date of Birth (Patient 3)
GLP-1 and Dose (Patient 3) Please Select SEMA - 1mg SEMA - 2mg SEMA - 4mg SEMA - 6.8mg SEMA - 10mg SEMA - 25mg TIRZ - 10mg TIRZ - 20mg TIRZ - 30mg TIRZ - 40mg TIRZ - 50mg TIRZ - 60mg
Specific Dosing Instructions (Patient 3)
Full Name (Patient 4)
Date of Birth (Patient 4)
GLP-1 and Dose (Patient 4) Please Select SEMA - 1mg SEMA - 2mg SEMA - 4mg SEMA - 6.8mg SEMA - 10mg SEMA - 25mg TIRZ - 10mg TIRZ - 20mg TIRZ - 30mg TIRZ - 40mg TIRZ - 50mg TIRZ - 60mg
Specific Dosing Instructions (Patient 4)
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