GLP-1 Refill Request Form

Patient Information:

Full Name

Date of birth

Phone *

Email *

Weight Loss Progress:

How much weight have you lost since starting GLP-1? *

What is your current weight? *

Current Dose on GLP-1: *

Side Effects:

Have you experienced any side effects while using GLP-1? *

Yes ( Please list any side effects experienced )

Side effects experienced *

Payment Information:

Preferred Payment Method for Refills:

Do have Credit Card or Debit Card on file: *

Yes

Card Number if yes (last 4 digits of card on file):

Mailing Address: *

Sign

Clear

______________________________

Do you have any referral bucks available to use?

Kindly note: We are open Monday through Thursday to process orders. You will hear from us within 24 hours of your submission, except on days we are closed. If you do not hear from us within this timeframe, please call the office at 540-343-0055 to follow up on your refill request.

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