Monthly Check In Refill Request
Name
First Name
Last Name
Email
example@example.com
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?
Please list pharmacy name, address and phone number to send your prescription.
Are you using Lily Direct Pharmacy and receiving vials?
Yes
No
I don't know
Would you like to increase your dose?
Would you like to schedule a follow up with the provider to discuss progress? questions or concerns?
Yes
No
If Yes, would you like:
In person visit
Virtual Video visit
Email through BodySite
Text
None
Submit
Should be Empty: