MinuteMD GLP-1 Refill Request

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GLP-1 Refill Information* This field is required.This questionnaire is for active patients to request a refill of any GLP-1 medications in which they are currently subscribed at MinuteMD. There will be options available in the form where you can discuss any questions you have with your provider and there will be options available for you to request any product and/or dosage changes with your provider. Any changes made will result in billing adjustments, and our billing department will reach out to you after submission to confirm the new pricing before proceeding. All refills and prescribed dosages are at the discretion of the prescriber based on information you have provided us, and who may reach out to you prior to filling to request further or updated information. By agreeing to this information, you are certifying that you are the patient and are answering the questions honestly.
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What is your full patient name as it appears in our Healthie portal?* This field is required.
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Please confirm your date of birth:
Date
Year
Month
Day
4
What is your email address?* This field is required.
example@example.com
5
Are you a current patient with no lapse in your subscription or are you a returning previous patient of ours requesting a new prescription and medication?* This field is required.It is extremely important to answer this question correctly, as the next series of questions will be determined by your answer here. Example: If you are an active subscriber simply requesting a refill because your current product is nearly out, choose option 1. If you were a previous patient of MinuteMD several months ago and had cancelled, but have now signed back up again in order to receive a new prescription and shipment of medication, please choose option 2.
I am a current subscriber with no lapse in my subscription with MinuteMD and I am requesting a refill of my prescription.
I was a previous subscriber at MinuteMD and have now signed back up with you in order to receive a new prescription and medication.
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Have you experienced any negative side effects on your previous prescription?* This field is required.
YESNO
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Please describe the side effects you experience in more detail:
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Small
Ok
Ok
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What is the date of your most recent injection of your previous prescription?* This field is required.
Date
Month
Day
Year
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Would you like to refill your same product or dosage (or clinical equivalent), or would you like to switch medications or dosages?This option can be used to switch from compounded semaglutide to compounded tirzepatide, or vice versa. Changing to a different GLP-1 product and/or dosage will result in a billing change. Our billing team will reach out to you after submission to discuss prior to submitting your refill.
I would like to remain on the current product and dosage.
I would like to switch to different product or change the dosage of my current product.
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Which changes would you like to request?Products and dosages are determined by a member of our care team when requesting a change of medication, are based off of your current dosage of your current medication, and must be approved by the provider before shipping from the pharmacy. We will contact you after submitting this questionnaire to discuss and confirm your requested choice.
I would like to increase the dose of my current medication.
I would like to decrease the dose of my current medication.
I would like to switch to a different medication.
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Would you like to add any of the following additional prescriptions to your refill?* This field is required.Do NOT choose Ondansetron or B-12 add-ons if you have already purchased these as part of any previously chosen bundle that includes these medications. If you choose them again here, you will be charged again for them.
Ondansetron 4mg / 15 Tablets For Nausea ($30.00)
Vitamin B-12 Shots - 10 Week Supply ($99.00)
None of the Above
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Do you have any additional medical information that you feel would be helpful for your provider to know when reviewing your refill request?
0/100
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Large
Normal
Small
Ok
Ok
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What address should this refill be shipped to?Please keep in mind that while most refills are shipped within 5 business days, shipping dates vary based on current order volume at the pharmacy and cannot be guaranteed. If you are unable to retrieve the package on the day of delivery please arrange for someone to pick it up from your shipping address and refrigerate it until you return.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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FedEx Delivery Manager Registration* This field is required.Our company utilizes FedEx Delivery Manager to provide our patients with tracking information from our pharmacy partners when your orders have shipped. It is mandatory for patients to register with this FREE service to ensure that you are notified immediately with tracking numbers to ensure you are able to promptly bring your shipment inside and place it in the refrigerator. If you are unable to be home on the day that FedEx says your order will be delivered, please arrange for someone else to pick up your delivery and refrigerate it. It is your responsibility to ensure the medication is refrigerated promptly upon delivery. By checking the box below, you acknowledge that you understand this policy and that you have registered with FedEx Delivery Manager and further agree that you will promptly refrigerate your order upon delivery or arrange for someone else to refrigerate it on your behalf. If you need to register, please visit: https://www.fedex.com/en-us/delivery-manager.html
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Terms & Conditions
Please read the following terms & conditions associated with this refill request: 

1. I understand that due to the multi-month quantity of medication that I will receive with this refill request that there is a minimum commitment of 3 additional months of service associated with my authorization once this request is submitted. 

2. Your provider will determine the appropriate dosage and formulation of medication to help minimize side effects and optimize results based on information you have provided to us. Some patients may benefit from a medication in a dosage that is not commercially available. For example, a doctor may prescribe a smaller or larger dose of a comparable drug than a patient needs because the comparable drug is only available in a certain dose. Not all patients can take medications in the standard dosage forms available (e.g., pills, tablets, or capsules). For example, if a patient has trouble ingesting pills due to age or a medical condition, a drug product can be compounded into a liquid, a topical cream, or even a chewable form that is easier to take. A patient may have an allergy and needs a medication to be made without a certain dye or additive. This is a nonexhaustive list of the use of compound medications. Your provider will determine the best medication and dosage suitable for your treatment which is a compounded version of medication. If this is a problem for you, please let us know immediately. 

3. Once your compounded medication has been shipped from the pharmacy, you will not be able to return it or be refunded for it. 

4. I understand that due to industry changes, a different pharmacy may be utilized to fulfill this refill than was used on any previous shipment. 

5. I understand that refills will be filled to the closest increment possible at the fulfilling pharmacy. 

6. I understand that different pharmacies may have different instructions and packaging sizes and that I agree to follow the instructions on the packaging of the refill received. 

7. If MinuteMD, Inc. staff or affiliated services determine that it is not medically appropriate to prescribe a refill of the medication requested, this authorization is considered null and void. 

8. I understand that any subscription cancellation request must be submitted at least 15 days prior to your next billing date. Requests sent less than 15 days prior to your next billing date will be subject to a final monthly charge before being cancelled. 


By acknowledging below, I certify that I have read and understand this agreement and/or had it explained to me, that I understand the risks and benefits of an asynchronous Telehealth appointment, and that I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction prior to requesting this refill.
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Do You Agree With These Terms & Conditions?* This field is required.Please read the following terms & conditions associated with this refill request: 1. I understand that due to the multi-month quantity of medication that I will receive with this refill request that there is a minimum commitment of 3 additional months of service associated with my authorization once this request is submitted. 2. Your provider will determine the appropriate dosage and formulation of medication to help minimize side effects and optimize results based on information you have provided to us. Some patients may benefit from a medication in a dosage that is not commercially available. For example, a doctor may prescribe a smaller or larger dose of a comparable drug than a patient needs because the comparable drug is only available in a certain dose. Not all patients can take medications in the standard dosage forms available (e.g., pills, tablets, or capsules). For example, if a patient has trouble ingesting pills due to age or a medical condition, a drug product can be compounded into a liquid, a topical cream, or even a chewable form that is easier to take. A patient may have an allergy and needs a medication to be made without a certain dye or additive. This is a nonexhaustive list of the use of compound medications. Your doctor will determine the best medication and dosage suitable for your treatment which is a compounded version of medication. If this is a problem for you, please let us know immediately. 3. Once your compounded medication has been shipped from the pharmacy, you will not be able to return it or be refunded for it. 4. I understand that due to industry changes, a different pharmacy may be utilized to fulfill this refill than was used on any previous shipment. 5. I understand that refills will be filled to the closest increment possible at the fulfilling pharmacy. 6. I understand that different pharmacies may have different instructions and packaging sizes and that I agree to follow the instructions on the packaging of the refill received. 7. If MinuteMD, Inc. staff or affiliated services determine that it is not medically appropriate to prescribe a refill of the medication requested, this authorization is considered null and void. 8. I understand that any subscription cancellation request must be submitted at least 15 days prior to your next billing date. Requests sent less than 15 days prior to your next billing date will be subject to a final monthly charge before being cancelled. 9. I understand that it is my responsibility to register with FedEx Delivery Manager to be notified of tracking numbers and expected delivery dates, and that it is also my responsibility to arrange refrigeration of the delivery promptly after delivery. 10. I understand that it is my responsibility to report non-delivery or incorrect deliveries to MinuteMD within 24 hours of delivery so that the issue can be rectified promptly. By acknowledging below, I certify that I have read and understand this agreement and/or had it explained to me, that I understand the risks and benefits of an asynchronous Telehealth appointment, and that I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction prior to requesting this refill.
YESNO
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Signature* This field is required.By signing this form, you certify that you have answered the questions above honestly to the best of your ability. Your computer's IP address is also being captured with this signature as additional verification of your signature.
Clear
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Upsell Calculation Totals
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Summary of Additional Items RequestedThis is the total amount due for the additional items requested. Please remit payment using the fields below.
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Total amount due for all additional options chosen.
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