Refill Request – Weight Loss Program Patients Only

This form is ONLY for patients that are currently enrolled in virtual weight loss.

Patient Name

Patient Date of Birth*

Month

Day

Year

Patient Phone Number*

Patient Email*

Which medication are you on?

Semaglutide

Tirzepatide

How many units are you injecting?

Have you lost weight or inches since your last visit?

Yes

No

N/A

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

Have you experienced any of the following side effects?

Abdominal Pain

Constipation

Nausea or Vomiting

Palpitations

None of the Above

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 FOR FURTHER COMMUNICATION REGARDING THIS REQUEST

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Email*

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