Prescription Refill Form Template
Hi! Please fill this form out to request a refill. Delivery may take up to 1-2 weeks, so please ensure you request ahead of time when you have around 2 doses left. Thank you!
Patient Name
*
First Name
Last Name
Patient Email Address
*
example@example.com
Patient Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medication
*
Semaglutide
Tirzepatide
Oral Meds
If Semaglutide, what dosage are you currently on?
*
0.25mg
0.50mg
1mg
1.7mg
2.4mg
If Tirzepatide, what dosage are you currently on?
*
2.5mg
5mg
Other
When did you start using this current vial/pill?
*
-
Month
-
Day
Year
Date
If you're on oral meds, please type the name and the dosage
*
Have you booked a follow-up appointment? This is required before you can receive a refill. Please visit: https://www.optimantra.com/optimus/patient/patientaccess/servicesall?pid=SmhtRzRsZTc1amVYVWxaTXdJVEtWZz09&lid=bk1DWjQ2bmJIT3NhZTVYaW50amhXQT09
*
Yes
Additional Information (supply refill such as needles or sharps container, etc)
Submit
Should be Empty: