Refill Request – Weight Loss Program Patients Only

This form is ONLY if you have been seen in the clinic within the last 90 days for weight loss. If so, you may qualify for a medication refill without having to make an appointment.

YOU WILL BE REFUNDED IF YOUR INFORMATION IS NOT CORRECT!

Have you had an appointment (virtual or in person) in the last 90 days?

* If you have not been seen in person or virtually by a provider in the last 90 days, you will need to be seen for a refill.

You can stop filling out this form and call us at 915-545-1261.

Patient Name

Patient Date of Birth

Month

Day

Year

Patient Phone Number

Patient Email

Have you lost weight or inches since your last visit?

Yes

No

N/A

If yes, How many? Type NA if not applicable.

Other side effects or concerns to report. Type NA if not applicable.

Do you want to stay at your current dosage or move up a dosage? (price may change)

Move up a Dosage

Stay at the current dosage

CHECK YOUR EMAIL AFTER SUBMISSION WITH IN 3 BUSINESS DAYS FOR YOUR PAYMENT LINK

YOUR REFILL REQUEST WILL NOT BE FILLED UNTIL

FORM AND PAYMENT ARE SUBMITTED