Monthly Check In & Refill Request
Name
First Name
Last Name
What is your weight today?
*
What dose are you currently on?
*
Are you experiencing any side effects?
*
Yes
No
If Yes, what are you experiencing?
Would you like to increase your dose?
What pharmacy do you want your prescription sent to? If using Lily direct vials or compound you do not need to answer this.
Do you have any updates or concerns you’d like your provider to know about?
Submit
Should be Empty: