MEDICATION REFILL ORDER FORM

MEDICATION REFILL ORDER FORM

***For Existing Patients ONLY***
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Must be resident or physically located in one of the following states: SC, NC, FL, AZ, NY, KS,

YesNo
Patient Email Address
example@example.com
Medication Name: Semaglutide? Tirzepatide? Other?
Current Weight?
Current Blood Pressure?
Have you experienced any negative side effects?
Any changes in medications, medical/surgical history since your last visit or order? Do you have any upcoming surgeries or procedures?
Do you want to stay on the current dose or increase it? Our office will contact you if further clarification is needed
Any other information you would like us to know? If this is a pharmacy refill, please provide pharmacy details
Please confirm shipping address below if shipping to home ($40) or indicate if shipping to office for pick up (no additional cost)
When was or will be your last dose, and what was the dosage?
Do you need more syringes?
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Please note: This form will not automatically place medication orders.

You will be sent an invoice when the order is approved by the provider. This invoice must be paid before we will order your medication from the pharmacy unless other arrangements have been discussed.

Freedom Wellness and Hydration, LLC
1516 Village Harbor, Second Floor Suite 2, Lake Wylie, SC 29710

(803) 752-4200

Hours: By Appointment Only

Tue - 10:00 am – 08:00 pm

Wed - 10:00 am – 08:00 pm

Thu - 10:00 am – 02:00 pm
Should be Empty: