Apretude Refill Request

Apretude Refill Request
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
What dose of Apretude is this for the patient?*

Maintenance (3mL IM every 2 months)Restart (3mL IM once a month x 2 doses then every 2 months thereafter)
When is patient due for injection?

MonthDayYear
Date
Where would you like Apretude delivered?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When would you like Apretude to be delivered to the office?*

MonthDayYear
Date
Please upload most recent HIV test/labs:

Cancelof
Please upload most recent office notes in reference to Apretude:

Cancelof
Should be Empty: