Weight Loss Reordering Form

Weight Loss Reordering Form
Name*

First NameLast Name
Current Medication

SemaglutideTirzepatide
Preferred Pharmacy

Grand Ave Pharmacy (B6 compound)Empower Pharmacy (B12 or B3 compound)
How much are you currently injecting? Please specify in mg or units. (Example: 5mg or 50 units) Semaglutide dosing: 0.25mg-2.4mg Tirzepatide dosing: 2.5mg-15mg
Do you need to change upcoming appointment to a sooner or later date? If yes, please text office at 316-302-4744

YesNo
Do you need additional follow up conversation prior to upcoming appointment or prior to ordering more medication?

YesNo
Please add any additional information here.
Please double check that information listed above is accurate for medication type and dosing as this could effect the medication or amount ordered for your upcoming visit.
Should be Empty: