Established Patient On Medication

Established Patient On Medication
I am an established patient and have been taking brand (or compounded) Ozempic or Wegovy (semaglutide) or Mounjaro (tirzapetide) from another provider. I am aware of contraindications and side effects of which I have none.

I am requesting RED Zone Health & Wellness, LLC take over my care and prescription for continuing this medication.

I will provide a completed contact and health history form. I understand there are regular/monthly provider follow up visits in person or via phone before prescriptions can be ordered. RED Zone Health & Wellness, LLC may require lab work for the continuation of these medications.

**I understand that RED Zone Health & Wellness, does not provide primary care services.**
Medication requested:

SemaglutideTirzapetideOther _____________________
My current dose is:
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: