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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.

YOU WILL BE REFUNDED IF YOUR INFORMATION IS NOT CORRECT!

Please answer all questions below.

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

Patient Phone Number

Patient Email

Have you lost weight or inches since your last visit?

YES

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

HOW TO PAY:

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

Submit this form after making payment.

YOU WILL BE REFUNDED IF YOUR INFORMATION IS NOT CORRECT!

SEMAGLUTIDE TIER 1

https://square.link/u/jRrfOcwq

SEMAGLUTIDE TIER 2

https://square.link/u/auvaGiao

TIRZEPATIDE TIER 1

https://square.link/u/NAhiYs3j

TIRZEPATIDE TIER 2

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

TIRZEPATIDE TIER 3

https://square.link/u/Zzgn03Qp

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.

THIS WEBSITE IS NOT INTENDED FOR THE PURPOSE OF PROVIDING MEDICAL ADVICE.

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.

No information contained in this website should be used by any reader to disregard medical and/or health related advice or provide a basis to delay consultation with a physician or a qualified healthcare provider. If you have a medical emergency, call your doctor or 911 immediately

Thank You!

Refill Request Form for Weight Loss Patients ONLY

Refill Request Form
for
Weight Loss Patients
ONLY