Weight Loss Medication Refill Request Form
Full Name
Email Address
example@example.com
What medication are you requesting a refill of? Please select 2 options
*
Semaglutide
Tirzepatide
Regular B12
Fat Burner (additional fee applies)
Please enter the current dose of your medication.
*
Dose Adjustment: Would you like to change your current dose?
*
Please Select
Increase
Decrease
Maintain the same
Current Weight and Height
*
Are you experiencing any side effects from your medication?
*
Yes
No
If yes please describe the side effects you are experiencing
Do you require any nausea medication included in your refill?
*
Yes
No
Have you made any significant changes to your diet or exercise routine since your last refill
*
Do you have any other concerns or questions for your weight loss practitioner? Please write them in the space provided.
PAY AND RENEW IN ONE STEP (OPTIONAL)
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1 MONTH BASIC WEIGHT LOSS
$
349.00
Quantity
1
2
3
4
5
6
7
8
9
10
3 MONTH BASIC WEIGHT LOSS PROGRAM-SM
3 MONTH ALL INCLUSIVE WEIGHT LOSS MANAGEMENT
$
899.00
Quantity
1
2
3
4
5
6
7
8
9
10
1 MONTH PREMIUM WEIGHT LOSS TIER 1
$
499.00
3 MONTH PREMIUM WEIGHT LOSS- TIER 1
3 MONTH ALL INCLUSIVE WEIGHT LOSS MANAGEMENT WITH TZ.
$
1,347.00
Quantity
1
2
3
4
5
6
7
8
9
10
1 MONTH PREMIUM WEIGHT LOSS TIER 2
$
599.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
3 MONTH PREMIUM WEIGHT LOSS TIER 2
3 MONTH ALL INCLUSIVE WEIGHT LOSS WITH TZ UP TO 10MG
$
1,617.00
Quantity
1
2
3
4
5
6
7
8
9
10
UPGRADE TO FAT BURNER
UPGRADE TO PACKAGE WITH FAT BURNER FOR $50.OO PER MONTH
$
50.00
Quantity
1
2
3
EXPRESS SHIPPING
NEED IT IN A HURRY? 1-2 BUSINESS DAY SHIPPING VIA USPS PRIORITY EXPRESS
$
30.00
PREPAID MY PACKAGE
This is for those whose request is included in their 3 month package
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
I acknowledge that this form is a request and does not guarantee changes will be made. I have provided accurate information regarding my current status.
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