GLP-1 Weight-Loss Order & Telehealth Intake — Semaglutide & Tirzepatide

Do you have an active semaglutide or tirzepatide prescription with D&D Pharmacy?

This helps us route you to the right process. If you're not sure, select No.

Step 1 of 3 Product selection

Select your GLP-1 therapy

Choose the products you'd like to order. Select all that apply, then choose your preferred supply option for each.

Online ordering is available for semaglutide and tirzepatide only. For peptides, wellness injectables or hormone therapy, call (786) 558-0702 or WhatsApp us.

Subtotal$0.00

Total$0.00

Your information

We'll use this to look up your prescription and contact you about your order.

First name *

Last name *

Email address *

Phone number *

Review your order

Confirm your details and selected products before submitting.

Subtotal$0.00

Total$0.00

Payment will be processed when we contact you to confirm your order. We accept cash, card, and most insurance.

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

Order submitted

Your order has been received. We'll contact you within 1 business day to confirm and process payment.

If you are experiencing a medical emergency, call 911. This form does not constitute a physician-patient relationship until the reviewing provider accepts your case.

Back to home

A Florida-licensed provider reviews your intake and, if appropriate, issues your prescription. $30 telehealth fee paid now; medication is paid at the pharmacy. Takes about 4 minutes.

Step 1 of 5 About you

About you

Legal name as it appears on your ID. * = required.

Legal first name *

Legal last name *

Date of birth *

Sex assigned at birth *

Height *

Weight *

Email address *

Phone number *

Florida address *

Must be a Florida address (Fla. Stat. §456.47).

I am currently located in Florida and the address above is accurate.

Health screening

A “yes” flags your intake for closer provider review — it does not automatically disqualify you.

Do any of these apply to you? *

Personal or family history of medullary thyroid cancer (MTC) or MEN2 Pancreatitis (ever) Gallbladder disease Gastroparesis / severe GI motility disorder Diabetes treated with insulin or a sulfonylurea (e.g. glipizide) Diabetic eye disease (retinopathy) Kidney disease History of an eating disorder None of these

Pregnant, trying to conceive, or breastfeeding? *

Yes No Not applicable

Drug allergies and reactions *

Current medications and supplements *

Current or past GLP-1 use (medication, dose, last injection)

Anything else your provider should know

Consent & signature

Required by Florida law before a provider can review your intake.

Telehealth consent — Fla. Stat. §456.47 Care is delivered remotely. A Florida-licensed physician reviews my answers and may request more information or an in-person visit. Telehealth is not for emergencies — I will call 911. I may withdraw consent at any time. I consent to telehealth services.

HIPAA privacy notice My health information is used for treatment, payment and healthcare operations as described in the Notice of Privacy Practices. It is never sold or used for marketing. I acknowledge the Notice of Privacy Practices.

Prescription acknowledgment A prescription is issued only if the physician finds it clinically appropriate. The $30 fee covers the provider review; medication is paid separately at the pharmacy. I understand.

Full legal name (e-signature) *

Typing your name is a legally binding electronic signature (UETA / E-SIGN Act).

Therapy & delivery

Your provider confirms the final dose. Medication is paid at the pharmacy.

Online ordering is available for semaglutide and tirzepatide only. For other therapies call (786) 558-0702 or WhatsApp us.

Medication subtotal (paid at pharmacy)$0.00

Telehealth fee (due online now)$30.00

Delivery

Ship to me

To your Florida address. Ships within 1 business day once authorized.

In-store pickup

9787 SW 72nd St, Miami. Ready within 24 hrs of authorization.

Review & submit

Check your details, then pay the $30 telehealth fee.

Telehealth fee — $30 due now

The one-time $30 telehealth review fee is paid now to begin your provider review. Your medication is paid separately at the pharmacy. Choose how you'd like to pay the $30:

Credit / debit card (online) — available soon

Pay the $30 securely by card. Online card payment is being enabled — for now please choose Zelle or cash.

Zelle

Send $30 via Zelle before we begin your review.

Cash at pharmacy

Pay the $30 in person at D&D Pharmacy. Your review begins once payment is received.

Send your $30 Zelle payment to:
D&D Pharmacy — info@danddpharmacy.com
Add your full name in the Zelle memo so we can match your payment. Your provider review begins once the $30 is received.

Bring $30 to D&D Pharmacy, 9787 SW 72nd St, Miami. Your provider review begins once the telehealth fee is received.

Pay your $30 telehealth fee securely by card. Card details are entered directly with our payment processor — D&D never sees or stores your card number.

Online card payment is being set up. Please choose Zelle or cash for now.

Card number

Expiration

CVV

Billing street address

Billing ZIP

Processing your $30 payment…

I certify this information is accurate and complete, and I authorize D&D Pharmacy and its providers to contact me by phone and email.

There was an error submitting your form. Please try again or call us at (786) 558-0702.

Submitted successfully

Your intake has been received. A Florida-licensed provider will review your responses and contact you within 1 business day.

If you are experiencing a medical emergency, call 911. This form does not constitute a physician-patient relationship until the reviewing provider accepts your case.

Back to home

Start your GLP-1 weight-loss prescription.

Do you have an active semaglutide or tirzepatide prescription with D&D Pharmacy?

Select your GLP-1 therapy

Your information

Review your order

Order submitted

About you

Health screening

Consent & signature

Therapy & delivery

Review & submit

Submitted successfully

What to expect

Privacy & security

Questions?

Florida telehealth notice