Medication Refill Request
Please complete this form to request a refill of your medication. Refill requests are reviewed by one of our licensed medical providers. Please allow adequate time for processing before you run out of medication.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Which medication are you requesting?
*
Please Select
Semaglutide
Tirzepatide
Semorelin
Tesamorelin
NAD+
What strength (mg) are you requesting?
*
Current Weight
*
How are you doing on your current dose?
*
I would like to stay on my current dose.
I would like to increase my dose.
I would like to decrease my dose.
I'm having side effects.
Please have someone contact me before processing my refill.
Are you experiencing any side effects or concerns?
Since your last refill, have there been any changes to your medical history, medications, allergies, or health conditions?
*
No Changes
Yes
Please Explain
*
How would you like to receive your medication?
*
Ship to my home
Pick up at The Wellness Center
If shipping to your home, please confirm your current shipping address.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Acknowledgement
*
I confirm that the information I have provided is accurate. I understand that refill requests are reviewed by a licensed medical provider and approval is not guaranteed. If my refill is approved, I will receive an invoice for payment. Once payment is received, my medication will be ordered for pickup or shipment.
Submit
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