Peptide & Injectable Intake

What are you interested in?

Select all products you'd like to discuss. Our physician will review your intake for the selected therapies.

GLP-1 Weight Management

Tirzepatide + L-Carnitine Semaglutide + L-Carnitine + Niacinamide

Wellness & Performance

NAD+ Sermorelin Glutathione B-Complex Testosterone Cypionate Methylcobalamin

Emergency Medications optional add-on

EpiPen / Epinephrine auto-injector — Add to my order (requires physician authorization)

An epinephrine auto-injector requires a prescription. The following questions help the physician confirm clinical eligibility and select the correct dose (0.3 mg adult / 0.15 mg pediatric).

Anaphylaxis history

Have you ever experienced anaphylaxis (a severe, life-threatening allergic reaction)?

Yes No Not sure

Known allergy triggers — check all that apply

Insect stings (bees, wasps, fire ants) Food allergy (peanuts, tree nuts, shellfish, etc.) Medication allergy (penicillin, NSAIDs, contrast dye, etc.) Latex Exercise-induced anaphylaxis Unknown / idiopathic Other

Describe your known allergen(s) in detail

Current EpiPen status

Do you currently have or carry an EpiPen?

Yes, and I carry it Yes, at home only I have one but it's expired No

Have you been prescribed an EpiPen before?

Yes No — first prescription

Dose selection

The standard adult dose is 0.3 mg (for patients ≥ 30 kg / ~66 lbs). The pediatric dose is 0.15 mg (for patients 15–30 kg). The physician will confirm the appropriate dose based on your weight.

Who is the EpiPen for?

Myself — adult (≥ 30 kg) Myself — pediatric (15–30 kg) My child

How many auto-injectors are you requesting?

1 (single) 2-pack (recommended — carry one, keep one at home)

Allergist care

Are you currently under the care of an allergist or immunologist?

Yes No No, but I've been referred

Any additional notes for the physician regarding your EpiPen request

If requesting a GLP-1, briefly describe your goals

Have you used a GLP-1 (semaglutide or tirzepatide) before?

No, first time Yes, same medication Yes, different GLP-1

Personal information

Used for your prescription label and physician review. All information is protected under HIPAA.

Identity

First name *

Last name *

Date of birth *

Biological sex *

Contact

Email address *

Phone number *

Street address (for shipping)

City

State

Biometrics

Height

Current weight (lbs)

Your BMI helps the physician calibrate your starting dose and titration schedule.

Thyroid health

GLP-1 medications carry an FDA black-box warning for thyroid C-cell tumors. These questions are required before any GLP-1 can be authorized.

Important: GLP-1 receptor agonists (semaglutide, tirzepatide) are contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Please answer all questions below honestly.

Thyroid cancer history — absolute contraindications

I have a personal history of medullary thyroid carcinoma (MTC) A first-degree relative has a history of medullary thyroid carcinoma I have been diagnosed with Multiple Endocrine Neoplasia type 2 (MEN 2) A first-degree relative has been diagnosed with MEN 2

Checking any of the above will flag your intake for immediate pharmacist review — a GLP-1 cannot be prescribed if any of these apply.

Current thyroid conditions

Hypothyroidism (underactive thyroid) Hyperthyroidism (overactive thyroid) Hashimoto's thyroiditis Graves' disease Goiter or thyroid nodules Other thyroid cancer (not MTC) None of the above

Are you currently taking thyroid medication?

No Yes — Levothyroxine / Synthroid Yes — other medication

Most recent TSH level and date (if known)

Not required, but helps the physician assess thyroid function at baseline.

Any additional thyroid notes for the physician

Heart & cardiovascular health

GLP-1 medications can increase resting heart rate and affect blood pressure. These questions help your physician assess safety and dose appropriately.

GLP-1s increase resting heart rate by an average of 2–4 bpm. Patients with pre-existing tachycardia, arrhythmia, or heart failure should disclose their full cardiac history.

Heart conditions — please check all that apply

Coronary artery disease (CAD) History of heart attack (MI) Heart failure (any type) Arrhythmia or irregular heartbeat Atrial fibrillation (AFib) Resting tachycardia (HR > 100 bpm) Bradycardia (HR < 50 bpm) Pacemaker or ICD History of stroke or TIA High blood pressure (hypertension) Low blood pressure (hypotension) None of the above

Vital signs

Approximate resting heart rate (bpm)

Check your smartwatch, phone health app, or measure manually.

Most recent blood pressure reading

Cardiac medications

Beta-blocker (metoprolol, atenolol, carvedilol…) Digoxin Antiarrhythmic (amiodarone, flecainide…) Anticoagulant (warfarin, apixaban, rivaroxaban…) ACE inhibitor or ARB (lisinopril, losartan…) None

Have you had a cardiac workup (EKG, echo, stress test) in the last 2 years?

No Yes — EKG Yes — Echocardiogram Yes — Stress test Yes — multiple

Any additional cardiac notes for the physician

Other medical history

Additional conditions that may affect which medications can safely be prescribed.

GI & pancreatic conditions

GLP-1s slow gastric emptying and have been associated with pancreatitis. Gastroparesis is a contraindication.

Gastroparesis (delayed stomach emptying) History of acute or chronic pancreatitis Inflammatory bowel disease (Crohn's, UC) Severe GERD or esophageal dysmotility None of the above

Metabolic & endocrine

Type 1 diabetes Type 2 diabetes Currently using insulin Prediabetes Adrenal insufficiency None of the above

Kidney & liver

Chronic kidney disease (CKD) Currently on dialysis Liver disease or cirrhosis None of the above

Reproductive

Currently pregnant Currently breastfeeding Planning pregnancy in next 12 months None / not applicable

Known drug allergies or adverse reactions

Current medications not listed in previous steps

Review & consent

Please read and confirm the following before submitting your intake.

Telehealth prescribing consent
I understand that a Florida-licensed physician will review my intake and, if clinically appropriate, issue a prescription for compounded injectable medications dispensed by D&D Pharmacy. I authorize this telehealth evaluation and consent to the physician reviewing my health information for prescribing purposes. I understand and consent to telehealth prescribing

GLP-1 contraindication acknowledgment
I confirm that I do not have a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN 2), and I understand that GLP-1 receptor agonists are contraindicated in patients with these conditions. I confirm I have no personal or family history of MTC or MEN 2

HIPAA authorization
I authorize D&D Pharmacy to use and disclose my protected health information (PHI) for the purpose of processing my prescription request, coordinating care with the prescribing physician, and billing my insurance where applicable. I understand I may revoke this authorization in writing at any time. I authorize use of my health information under HIPAA

Injectable medication acknowledgment
I understand that compounded injectable medications require proper storage, sterile injection technique, and regular follow-up with my prescribing physician. I have received or will request administration training before beginning therapy. I understand the requirements for self-administered injectable therapy

Full legal name (electronic signature) *

By typing your name above you are electronically signing this intake form and attesting that all information provided is accurate and complete to the best of your knowledge.

Submitting this form does not guarantee a prescription will be issued. All prescriptions are authorized by a licensed Florida physician following clinical review. Expect a response within 1 business day.

There was a problem submitting your intake. Please try again or call us at (786) 558-0702.

✓

Intake submitted

A pharmacist will review your responses and contact you within 1 business day. Check your email for a confirmation.

Back to home

Intake form for compounded injectable therapy.

What are you interested in?

Personal information

Thyroid health

Heart & cardiovascular health

Other medical history

Review & consent

Intake submitted

What to expect

Questions?

Storage & shipping

Florida telehealth notice