Weight Loss Med Refill Request

Med Refill Request

The Crafted Clinic Weight Loss Program
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Height
Current Weight
Patient Phone Number
Format: (000) 000-0000.
Patient Email Address
example@example.com
Please list your current medication and dose (example: Semaglutide 20 units).
Are you having any adverse side effects?
If yes, please explain
Signature
Agreements:
If your address has changed, please contact the office (417) 221-5700 to place your order.

ATTENTION TIRZEPATIDE PATIENTS

Our pharmacy has recently made a change to the concentration of Tirzepatide, which means there are updates to dosing and pricing.

To ensure every patient receives the correct dosing instructions and understands the updated pricing, we have temporarily turned off online ordering for Tirzepatide.

Need to place an order?
Please contact our office directly. Our team will review the updated pricing and dosing with you before your order is placed.

Please do not use your previous dosing instructions with a new vial unless our team has confirmed your updated dose.

Thank you for your patience as we make this transition and continue to prioritize safe, accurate dosing.
— The Crafted Clinic

My Products

Semaglutide 1ml (100 units)

This includes vial of medication for office pick up. If you need home shipping please add that option below.

$169.00 Quantity

Semaglutide 2ml (200 units)

This includes vial of medication for office pick up. If you need home shipping please add that option below.

$299.00 Quantity

Semaglutide 4ml (400 units)

This includes vial of medication for office pick up. If you need home shipping please add that option below.

$499.00 Quantity

HOME SHIPPING

Home shipping orders can take up to 3-7 business days to arrive. If this option is not selected, your order will be placed for office pick up.

$35.00 Quantity

Total

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

FOR HOME SHIPPING ORDERS, PLEASE ADD THE HOME SHIPPING FEE.

If the home shipping fee is not added, the order will default to office pickup.
Should be Empty: