Sermorelin Intake Form - SimpleFix Rx

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Doctor's Notes

Let's Get Started

First Name*

Last Name*

Email*

Phone*

Date Of Birth*

Month

Day

Year

Sex*

State*

Please upload a government issued form of ID (Driver's License, Passport, etc). Please be sure that your full name and photo are easily visible.*

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 128 MB.

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We're sorry, but SimpleFixRx is currently not available in your selected state. Please reach out to support@simplefixrx.com. We may still be able to help you get the prescription you are looking for!

Medical History

Are you pregnant, planning to become pregnant, or breastfeeding?*

Currently pregnant

Planning to become pregnant within the next 6 months

Breastfeeding

None of the above

What benefits are you seeking? (please check all that apply)*

Muscle gain

Fat loss

Improved healing

Memory/cognitive benefits

Better sleep

General anti-aging

Other

Do any of the following apply to you? Please select all that apply.*

Active cancer diagnosis

Disease of the pituitary gland

Untreated hypothyroidism

Uncontrolled diabetes

Intracranial lesion/tumor

Heart failure

None of the above

Your Weight (Lbs)*

Height (Feet)*

Height (Inches)*

Bmi

Weight(Lbs)

Height (feet/inches)

Height (cm)

Please list all current medical conditions. Please type N/A if none.*

Please list all your current medications, including prescription, over-the-counter, and supplements, including dosages. Please type N/A if none.*

Please list all of your known allergies. Please type N/A if none.*

Is the any additional medical history our provider should know during the consult?

Please upload your recent lab results, including hormone levels (thyroid, IGF-1 etc.) for review.

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Accepted file types: jpg, jpeg, png, pdf, Max. file size: 128 MB.

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Please list all current medical conditions. Please type N/A if none.*

High Blood Pressure

Type 2 Diabetes

High Cholesterol

Pulmonary Condition

None

Other

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How often do you exercise?*

3-4 days a week

2-3 days a week

Very little

Never

Other

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Which of the following weight loss medications have you tried?*

GLP-1

GLP-1/GIP

Orlistat (Xenical, Alli)

Phentermine-topiramate (Qsymia)

Reg Phentermine 37.5 mg

Naltrexone-bupropion (Contrave)

Liraglutide (Saxenda)

None, I have not tried Rx weight management meds

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Have you had serious issues with gallbladder within the past 12 months? *

Pain in your upper stomach (abdomen)

Yellowing of the skin or eyes (jaundice)

Clay-colored stools

I have active Gallbladder Disease

No, I do not have any of these symptoms

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Have you been diagnosed with inflammation of your pancreas (pancreatitis) in the past 6 months?

Yes

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Have you been diagnosed with kidney disease in the past 12 months? *

Yes

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Do you have sleep conditions such as sleep apnea?*

Yes, I have Sleep Apnea

No, I do not have Sleep Apnea

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Are you on hormone therapy?*

Creams

Pellet

No, I am not on hormone therapy

Not currently, but I should be

I am happy with my hormone health

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In the past 12 months, I...*

Experienced no mental health problems, ie anxiety, depression

I am on medication, but feel in control of my mental health

I deal with stress, but no medication. Some days are stressful, but I feel okay.

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Have you ever been diagnosed with medullary thyroid cancer or MEN syndrome?*

Yes

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Do you have an active eating disorder?*

Yes

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Are you currently pregnant or breastfeeding? GLP-1 cannot be taken while breastfeeding.*

Yes

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Are you planning on getting pregnant in the next year?*

Yes

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Do you have type 1 diabetes*

Yes

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Are you currently struggling with substance abuse or dependency problems?*

Yes

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Have you had bariatric surgery within the past 18 months*

Yes

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Have you visited us before?

Yes, I’m a returning patient

No, I’m a new patient

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Which type of consultation would you prefer?*

Video

Phone

Asynchronous/Email and Text Message (Fastest Option)

***Important Notice:

New compliance measures require all new (or) returning patients seeking an increase in their medication to schedule a call with a physician. If you are a new patient, or are seeking an increase in your dose, you will be directed to schedule your online doctor consult immediately following your payment. If answered incorrectly, requested medication could be delayed (or) your order could be canceled and payment refunded. For any question, please contact support@simplefixrx.com

Weight Management Rx History

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Have you taken any GLP-1 weight loss medications? Please list all medications.*

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Did any of the following side effects cause you to discontinue treatment?*

Nausea

Diarrhea

Stomach (abdominal) pain

Vomiting

Constipation

No side effects

Other...

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Please specify other side effects caused by taking any GLP-1 weight loss medications...*

Did you previously purchase your weight loss medication from SimpleFix?*

Yes

Where did you purchase your weight loss medication from previously?

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What was the ending medication and strength of your previous treatment?*

0.5 mg GLP-1 (approximate)

1.0 mg GLP-1 (approximate)

1.7 mg GLP-1 (approximate)

2.4 mg GLP-1 (approximate)

5 mg GLP-1/GIP (approximate)

7.5 mg GLP-1/GIP (approximate)

10 mg GLP-1/GIP (approximate)

12.5 mg GLP-1/GIP (approximate)

15 mg GLP-1/GIP (approximate)

Unknown

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What was your most recent medication/dosage strength?*

0.5 mg GLP-1

1.0 mg GLP-1

1.7 mg GLP-1

2.4 mg GLP-1

5 mg GLP-1/GIP

7.5 mg GLP-1/GIP

10 mg GLP-1/GIP

12.5 mg GLP-1/GIP

15 mg GLP-1/GIP

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Would you like the strength of your prescription increased?*

Yes, I'm having a slow or plateau in weight loss and would like to increase the strength of my prescription according to protocol.

No, I'm happy with the amount I'm losing and do not wish to increase the strength of my prescription.

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Studies shows adding B12 can help reduce nausea and increase energy. Is feeling energetic important to you?*

Yes

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Adding glycine to your weight lost regime it can help muscle retention. Is muscle retention important to you?*

Yes

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Have you had gastrointestinal issues or nausea while on GLP-1 medications?*

Yes

READ OUR TERMS & CONDITIONS POLICY

TELEMEDICINE PATIENT CONSENT PURPOSE:

The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares.

RECORDS: Telecommunications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies. TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment. PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication. By signing this form, I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.

I agree to terms and conditions*

I agree to terms and conditions

By using SimpleFix you are consenting to the practices described in the privacy policy*

By using SimpleFix you are consenting to the practices described in the privacy policy

Sign & Consent

By signing here, you agree that you have read HIPAA, telemedicine consent, Disclosure and agree that you are the individual in DL and Photo. SimplefixRx uses CareValidate for medical decisions and patient care.

Sign here*

Shipping & Billing Information

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Billing Address*

Same as Shipping Address

Street Address Address Line 2 City State ZIP Code

Requested Rx

Important Update on Tirzepatide

Tirzepatide is no longer on the FDA shortage list and is now commercially available. Due to this, compounded Tirzepatide is no longer permitted.

For Existing Patients:

If you’ve been successfully using Tirzepatide and wish to continue your treatment, we can still help you get the prescription you need. Contact us at support@simplefixrx.com or text 682-245-2031, and our team will guide you through your options.

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Pharmacy Routing - Luxe Med

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Pharmacy Routing - Elysium Pharmaceuticals

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Pharmacy Routing - Red Rock Springville

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Pharmacy Routing - Red Rock St George

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Product Options - Elysium Pharmaceuticals*

2 mg / 0.5 mg Weekly GLP-1 - $300 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

4 mg / 1.0 mg Weekly GLP-1 - $350 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

6 mg / 1.5 mg Weekly GLP-1 - $375 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

10 mg / 2.5 mg Weekly GLP-1 - $400 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

GLP-1 Starter Package - $595 2 mg + 2 mg + 4 mg (3-Month Supply)

GLP-1 Performance Package - $795 4 mg + 6 mg + 10 mg (3-Month Supply)

GLP-1 Max Package - $895 10 mg + 10 mg + 10 mg (3-Month Supply)

10 mg per ml, 2ml vial, 20 mg total / 5 mg Weekly GLP-1/GIP - $390 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

15 mg per ml, 2ml vial, 30 mg total / 7.5 mg Weekly GLP-1/GIP - $450 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

20 mg per ml, 2ml vial, 40 mg total / 10 mg Weekly GLP-1/GIP - $525 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

25 mg per ml, 2ml vial, 50 mg total / 12.5 mg Weekly GLP-1/GIP - $550 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

30 mg per ml, 2ml vial, 60 mg total / 15 mg Weekly GLP-1/GIP - $625 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

GLP-1/GIP Starter Package - $795 10 mg/ml + 10 mg/ml + 15 mg/ml (3-Month Supply)

GLP-1/GIP Performance Package - $1250 20 mg/ml + 25 mg/ml + 30 mg/ml (3-Month Supply)

GLP-1/GIP Max Package - $1450 30 mg/ml + 30 mg/ml + 30 mg/ml (3-Month Supply)

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Product Options - Red Rock*

0.5 mg GLP-1 - $300 4 Injections, 4-Week Supply, Single-Pack Syringes

1.0 mg GLP-1 - $350 4 Injections, 4-Week Supply, Single-Pack Syringes

1.0 mg GLP-1 - $795 4 Injections, 4-Week Supply, Single-Pack Syringes (2 refills)

1.7 mg GLP-1 - $375 4 Injections, 4-Week Supply, Single-Pack Syringes

2.4 mg GLP-1 - $400 4 Injections, 4-Week Supply, Single-Pack Syringes

2.4 mg GLP-1 - $995 4 Injections, 4-Week Supply, Single-Pack Syringes (2 refills)

4.25 mg GLP-1/GIP - $390 4 Injections, 4-Week Supply, Single-Pack Syringes

6.375 mg GLP-1/GIP - $450 4 Injections, 4-Week Supply, Single-Pack Syringes

8.5 mg GLP-1/GIP - $525 4 Injections, 4-Week Supply, Single-Pack Syringes

11 mg GLP-1/GIP - $550 4 Injections, 4-Week Supply, Single-Pack Syringes

13.5 mg GLP-1/GIP - $625 4 Injections, 4-Week Supply, Single-Pack Syringes

Product Options*

Sermorelin 3ml - muscle building - $165

Sermorelin 10ml - muscle building - $299

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Product Options - RxCompound Store*

GLP1/ 1 with Glycine 2.5mg / 5mg/ml - $300 GLP1/ 1 with Glycine 2.5mg / 5mg/ml in 1 ml vial --------------- Directions 24 units of (0.6mg) Subcutaneous weekly

GLP1/ 1 with Glycine 3.75mg/ 12.5mg - $350 GLP1/ 1 with Glycine 3.75mg/ 12.5mg 2.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 60 units (0.9 mg) subcutaneous weekly

GLP1/ 1 with Glycine 6.25mg/ 12.5mg - $375 GLP1/ 1 with Glycine 6.25mg/ 12.5mg 2.5 ml vial ---------------- 4 Injections, 4-Week Supply, Directions inject 60 units (1.5mg) subcutaneous weekly

GLP1/ 1 with Glycine 8.75mg/ 17.5mg - $400 GLP1/ 1 with Glycine 8.75mg/ 17.5mg 3.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 80 units (2.0 mg) subcutaneous weekly

GLP1/ 1 with Glycine Starter Package - $595 month 1 GLP 1/ Glycine 2.5mg/5mg/ ml in 1ml vial Inject 24units (0.6mg) subcutaneous. month 2 GLP 1/ Glycine 2.5mg/5mg/ ml in 1ml vial Inject 24units (0.6mg) subcutaneous. Month 3 GLP 1/ glycine 3.75mg/12.5mg in 2.5ml vial directions inject 60 units (0.9mg) subcutaneous weekly

GLP1/ 1 with Glycine Performance Package - $795 GLP1/ 1 with Glycine 3.75mg/ 12.5mg 2.5 ml vial /Syringes Directions inject 60 units (0.9 mg) subcutaneous weekly Vial 2 GLP1/ glycine 6.25mg/ 12.5mg in 2.5ml vial directions Inject 60 units weekly Subcutaneous Vial 3 GLP1/ Glycine 17.5 mg in 3.5 ml vial Inject 80 units weekly (2mg) subcuta

GLP1/ 1 with Glycine Max Package - $895 GLP1/ 1 with Glycine 8.75mg/17.5mg in 3.5ml vial-------------- 12 injections, 12 Week Supply, Directions Inject 80 units (2mg) subcutaneous weekly

GLP1/ GIP Glycine 20mg/10mg - $450 GLP1/ GIP /Glycine 20mg/10mg in a 2ml vial Directions inject 45 units (4.5mg) SQ weekly

GLP1/ GIP /Glycine 30mg/ 7.5mg - $525 GLP1/ GIP /Glycine 30mg/7.5mg in a 3ml Vial Inject 68 units (6.8mg) SQ weekly

GLP1/ GIP /Glycine 40mg/10mg - $550 GLP1/ GIP /Glycine 40mg/10mg in a 2ml Vial ---- Directions inject 45 units (9mg) SQ weekly

GLP1/ GIP /Glycine 60mg/15mg - $625 GLP1/ GIP /Glycine 60mg/15mg in a 3ml Vial -------Directions Inject 68 units (13.6mg) SQ weekly

GLP1/ GIP with Glycine Starter Package - $795 GLP1/ GIP with Glycine Starter Package - Month 1 4.5mg weekly, Month 2 4.5 mg weekly Month 3 6.8 mg weekly

Performance Package GLP1/ GIP with Glycine - $1250 Performance Package GLP1/ GIP with Glycine- Vial 1 6.8 mg weekly, Vial 2 9 mg weekly Vial 3 13.6mg weekly

Max Package 3 month supply (ships monthly) GLP1/ GIP 60mg/Glycine 15mg - $1450 Max Package 3 month supply (ships monthly) GLP1/ GIP 60mg/Glycine 15mg in a 3ml Vial -------12 weeks Supply Directions Inject 68 units (13.6mg) SQ weekly 3 shipments

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Product Options - Specialty Rx Care*

GLP1/ 1 with Glycine 2.5mg / 5mg/ml - $300 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

GLP1/ 1 with Glycine 3.75mg/ 12.5mg - $350 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

GLP1/ 1 with Glycine 6.25mg/ 12.5mg - $375 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

GLP1/ 1 with Glycine 8.75mg/ 17.5mg - $400 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

GLP1/ 1 with Glycine Starter Package - $595 2 mg + 2 mg + 4 mg (12-week supply dispensed monthly)

GLP1/ 1 with Glycine Performance Package - $795 4 mg + 6 mg + 10 mg (12-week supply dispensed monthly)

GLP1/ 1 with Glycine Max Package - $895 10 mg + 10 mg + 10 mg (12-week supply dispensed monthly)

GLP1/ GIP Glycine 20mg/10mg - $450 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

GLP1/ GIP /Glycine 30mg/ 7.5mg - $525 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

GLP1/ GIP /Glycine 40mg/10mg - $550 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

GLP1/ GIP /Glycine 60mg/15mg - $625 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

GLP1/ GIP with Glycine Starter Package - $795 10 mg/ml + 10 mg/ml + 15 mg/ml (12-week supply dispensed monthly)

Performance Package GLP1/ GIP with Glycine - $1250 20 mg/ml + 25 mg/ml + 30 mg/ml (12-week supply dispensed monthly)

Max Package 3 month supply (ships monthly) GLP1/ GIP 60mg/Glycine 15mg - $1450 30 mg/ml + 30 mg/ml + 30 mg/ml (12-week supply dispensed monthly)