Weight Loss Med Refill Request

Full Name*

First NameLast Name

Date of Birth*

Date

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*

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)