REFILL REQUEST FORM

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*

SemaglutideTirzepatide

Please enter the current dose of your medication.*

Dose Adjustment: Would you like to change your current dose?*

Current Weight and Height*

Are you experiencing any side effects from your medication?*

YesNo

If yes please describe the side effects you are experiencing

Do you need nausea medication called in to your local pharmacy?*

YesNo

If yes, please enter your complete pharmacy info below.

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)

3 MONTH BASIC WEIGHT LOSS PROGRAM-SM

3 MONTH ALL INCLUSIVE WEIGHT LOSS MANAGEMENT

$899.00 Quantity

3 MONTH PREMIUM WEIGHT LOSS- TIER 1

3 MONTH ALL INCLUSIVE WEIGHT LOSS MANAGEMENT WITH TZ.

$1,347.00 Quantity

3 MONTH PREMIUM WEIGHT LOSS TIER 2

3 MONTH ALL INCLUSIVE WEIGHT LOSS WITH TZ UP TO 10MG

$1,617.00 Quantity

UPGRADE TO FAT BURNER

UPGRADE TO PACKAGE WITH FAT BURNER FOR $50.OO PER MONTH

$50.00 Quantity

EXPRESS SHIPPING

NEED IT IN A HURRY? 1-2 BUSINESS DAY SHIPPING VIA USPS PRIORITY EXPRESS. THIS DOES NOT INCLDE PROCESSING TIME.

$30.00

PREPAID MY PACKAGE

This is for those whose request is included in their 3 month package

$ Free Quantity

Subtotal

$0.00

Shipping

$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Afterpay

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.