Physicians' Choice Infusion Pharmacy

Luxe Wellness Lounge Rx Form | Brandon Perry M.D(Supervising Physician)

Luxe Wellness Lounge | luxe-wellnesslounge.com| Phone:210.257.5812

Name
Address
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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 .