Apretude Refill Request
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where would you like Apretude delivered?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When would you like Apretude to be delivered to the office?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please upload most recent HIV test/labs:
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Please upload most recent office notes in reference to Apretude:
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Submit
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