Weight Loss Med Refill Request

Full Name*

First NameLast Name

Date of Birth*

Date

Gender*

Height*

Current Weight*

Patient Phone Number*

Mailing Address *

Street Address

Street Address Line 2

CityState / 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?*

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.By checking this box, I verify I have not been recently diagnosed with multiple endocrine neoplasia syndrome. I do not have family history of medullary thyroid cancer or history of Pancreatitis.

If your address has changed, please contact the office (417) 221-5700 to place your order.

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.

$175.00 Quantity

Semaglutide 2ml (200 units)This includes vial of medication for office pick up. If you need home shipping please add that option below.

$330.00 Quantity

Semaglutide 4ml (400 units)This includes vial of medication for office pick up. If you need home shipping please add that option below.

$560.00 Quantity

Tirzepatide 1ml (100 units)This includes vial of medication for office pick up. If you need home shipping please add that option below.

$250.00 Quantity

Tirzepatide 2ml (200 units)This includes vial of medication for office pick up. If you need home shipping please add that option below.

$350.00 Quantity

Tirzepatide 3ml (300 units) This includes vial of medication for office pick up. If you need home shipping please add that option below.

$425.00 Quantity

Tirzepatide 4ml (400 units) This includes vial of medication for office pick up. If you need home shipping please add that option below.

$500.00 Quantity

Tirzepatide 5ml (500 units) This includes vial of medication for office pick up. If you need home shipping please add that option below.

$550.00 Quantity

Tirzepatide 6ml (600 units) This includes vial of medication for office pick up. If you need home shipping please add that option below.

$600.00 Quantity

HOME SHIPPINGHome shipping orders can take up to 5-7 business days to arrive via FedEx. If this option is not selected, your order will be placed for office pick up.

$35.00 Quantity

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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.