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

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?

If yes please describe the side effects you are experiencing

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

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

Shipping

Total

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.