Physicians' Choice Infusion Pharmacy

ETX GLP1 Form |Kelly Warren, M.D (Supervising Physician)

East Texas Inject | www.etxinject.com | Phone: 903.802.5167| Krystal Gilmore, FNP |

Name
Address
Shipping
Ship to another address:

Compounded Semaglutide

Strengths of Compounded Semaglutide(include, but not limited to):0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.25 mg, 1.5 mg, 2 mg, etc.

Compound with (must select one):
Sig: Inject/mg

Compounded Tirzepatide

Strengths of Compounded Tirzepatide (include, but not limited to):2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, etc.

Compound with:
Sig: Inject/mg
Diagnosis
Additional Longevity Compounds:
Clear Signature
Date / Time

Thank you for choosing Physicians Choice Infusion Pharmacy!

If you have any questions, please call us at 817-993-5448  or send an email to Compounding@pcipharmacy.com .