Routine Refill Request
Patient-facing refill request form. Please complete the required acknowledgments and only use this form for routine refills.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Routine Refill Request Acknowledgments
Acknowledge routine refill request only; not for urgent or emergency needs
*
I acknowledge
Acknowledge emergency concerns should not be submitted here and should be addressed through appropriate urgent care channels
*
I acknowledge
Medication Needing Refill
Medication Needing Refill
*
Estradiol patch
Estradiol gel
Estradiol vaginal ring (Femring)
Estradiol spray
Oral estradiol
Vaginal estrogen cream/tablet/ring
Micronized progesterone
Slynd
Norethindrone acetate
Norethindrone 0.35 mg
Testosterone
Minoxidil
Wegovy
Zepbound
Foundayo
Other
Anything else about this refill?
Current dose and how taken
*
Pharmacy name and city/location
*
If you are not sure your treatment is working well, your symptoms are not where you want them to be, or you would like your provider to review your treatment plan, complete the symptom tracker at www.menopauselouisiana.com/track and select Provider Review.
I understand and will let my provider know if any of the following applies to me: If I have a uterus and use progesterone or another progestin for uterine protection, I will tell my provider if I stop it, change it, or am no longer taking it as prescribed. If I use an IUD for uterine protection, I will tell my provider if it has been removed or if it is more than 5 years old
Yes
Are you taking your medications exactly as instructed by The Menopause Clinic?
*
Yes
No
Not sure
What has been different?
Major Health Changes
Have there been any major health changes?
*
Yes
No
Not sure
Please describe the major health changes
*
Testosterone Acknowledgments
Have you completed or scheduled your required testosterone visit?
*
I have completed my required testosterone visit within the month before this refill is needed.
My required testosterone visit is already scheduled.
I have not completed an in-person visit for the purpose of a testosterone refill within the last month. I understand that I will need to schedule and complete an in-person visit before my testosterone refill can be provided. I can schedule my visit and review all requirements for continuing testosterone here: https://www.menopauselouisiana.com/continuing-testosterone or go to the member hub anytime at www.menopauselouisiana.com and click on testosterone for the requirements.
Submit Refill Request
Should be Empty: