Med Refill Request
The Crafted Clinic Weight Loss Program
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Height
*
Current Weight
*
Patient Phone Number
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Email Address
*
example@example.com
Please list your current medication and dose (example: Semaglutide 20 units).
*
Are you having any adverse side effects?
*
Please Select
Yes
No
If yes, please explain
Signature
*
Agreements:
*
I understand that my request has to reviewed and approved by our licensed healthcare staff. If declined, I will be refunded (which can take 5-10 business days).
I agree to be contacted by The Crafted Clinic for follow up as needed.
My Products
prev
next
( X )
Semaglutide 1ml (100 units)
This includes vial of medication for office pick up. If you need home shipping please add that option below.
$
175.00
Quantity
1
2
3
4
5
6
7
8
9
10
Semaglutide 2ml (200 units)
This includes vial of medication for office pick up. If you need home shipping please add that option below.
$
330.00
Quantity
1
2
3
4
5
6
7
8
9
10
Semaglutide 4.5ml (450 units)
This includes vial of medication for office pick up. If you need home shipping please add that option below.
$
630.00
Quantity
1
2
3
4
5
6
7
8
9
10
Tirzepatide 1ml (100 units)
This includes vial of medication for office pick up. If you need home shipping please add that option below.
$
260.00
Quantity
1
2
3
4
5
6
7
8
9
10
Tirzepatide 2ml (200 units)
This includes vial of medication for office pick up. If you need home shipping please add that option below.
$
505.00
Quantity
1
2
3
4
5
6
7
8
9
10
HOME SHIPPING
Overnight shipping (once processed-average 3-5 business days) to your house via FedEx
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Submit
Should be Empty: