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Refill Request Form
for
Weight Loss 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.

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YOU WILL BE REFUNDED IF YOUR INFORMATION IS NOT CORRECT!

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Please answer all questions below.

* 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.

Have you lost weight or inches since your last visit? Required
Have you experienced any of the following side effects? Required
Do you want to stay at your current dosage or move up a dosage? (price may change) Required

HOW TO PAY:

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Click below on the correct Virtual Weight Loss Subscription Tier to pay for your 30 day dosage.

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Submit this form after making payment. 

YOU WILL BE REFUNDED IF YOUR INFORMATION IS NOT CORRECT!

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SEMAGLUTIDE TIER 1

https://square.link/u/jRrfOcwq

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SEMAGLUTIDE TIER 2

https://square.link/u/auvaGiao

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TIRZEPATIDE TIER 1

https://square.link/u/NAhiYs3j

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TIRZEPATIDE TIER 2

https://square.link/u/63piuQUA

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TIRZEPATIDE TIER 3

https://square.link/u/Zzgn03Qp

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YOUR REFILL REQUEST WILL NOT BE FILLED UNTIL FORM AND PAYMENT ARE SUBMITTED​

Thanks for submitting! We will process your order the next business day.

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The information contained in this website is not intended to recommend the self management of health problems or wellness. It is not intended to endorse or recommend any particular type of medical treatment. Should any reader have any health care related questions, promptly call or consult your physician or healthcare provider.

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