Weight Loss Medication Refill Form

Refill Request Processing

Refill requests are reviewed and processed during our regular business hours:

Requests submitted outside of these hours will be processed on the next business day.

Shipping Information

Please note that our pharmacy does not ship medications on Fridays.

Orders submitted Monday through Wednesday are typically processed and delivered by Friday.
Orders submitted Thursday or Friday will generally be processed and shipped the following Monday.

Please allow additional processing time during holidays, weather events and periods of high volume.

Full Name

First NameLast Name

Today’s Date

Date

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Last Injection

Date

What Is Your Current Weight?

Your Current Weight Loss Medication And Dose

Do You Want To Continue The Current Dose?

Would You Like To Speak With A Provider About Your Refill?

Are You Experiencing Any of These Side Effects

Do You Need Nausea Medication Sent To Your Pharmacy?

Has Your Address Changed

Yes (Please Enter New Address)

Do You Authorize Peak Health And Wellness To Use The Same Card Used At Previous Visit?

What are the last 4 digits of the card you authorize Peak Health to use?

Digital Signature