Physicians' Choice Infusion Pharmacy

Phamily Weight Wellness Center Rx Form

Address: 2419 Coit Rd, Ste B Plano, TX 75075 | www.phamilyhealth.com| Phone: 469-443-0093

Supervising Physician:Theresa Garza, DO

Provider: Melissa Lopez Pham, FNP-C

Name
Address
Please select one option:
Ship to a different address:

Compounded Semaglutide

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

Compounded Tirzepatide

 

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 .