MediZen Revitalize – Follow-Up & Refill Request
This form is required prior to follow-up appointments or medication refills. Please provide updated information to ensure safe and effective continuation of treatment.
Patient Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
DOB
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which treatments are you currently using? (Select all that apply)
*
GLP-1 Medication
Peptide Therapy
Testosterone Therapy
Other
Not currently taking medication
If Other, please specify:
Current Weight (lbs):
*
Starting Weight (if known):
Have you experienced any side effects since your last visit? (Select all that apply):
*
None
Nausea
Vomiting
Constipation
Diarrhea
Abdominal Pain
Headache
Fatigue
Injection site reaction
Mood changes
Dizziness
Other
If you selected any side effects, please describe severity and duration:
Have you been taking your medication as prescribed?
*
Yes
Missed 1–2 doses
Missed multiple doses
Stopped temporarily
Stopped completely
Are you currently pregnant, trying to conceive, or breastfeeding?
*
No
Yes
List any new medical diagnoses, medication changes, procedures, or health concerns since your last visit. If none, type N/A.
*
Are you requesting a dose adjustment?
*
No change requested
Request dose increase
Request dose decrease
Unsure – provider discretion
Current Medication & Dose (example: Semaglutide 0.5 mg weekly):
*
Date of last injection or dose:
*
-
Month
-
Day
Year
Date
Have you experienced severe abdominal pain, persistent vomiting, chest pain, difficulty breathing, or signs of allergic reaction since your last visit?
*
No
Yes
If yes, explain and seek immediate medical evaluation if not already done.
If you are receiving Testosterone Therapy, have you completed required lab monitoring as instructed?
*
Yes
No
Not applicable
Current Height (inches) – if different from initial intake
I confirm that I am requesting provider review for continued treatment and refill consideration.
*
Yes
No
Patient Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: