3-Peat Wellness Prescription Refill Request Follow Up Date * MM DD YYYY Client Information * Monthly check-in: Please fill this form out when you are ready to order your next month of medication. We will contact you within 3 Business Days. (Mon-Friday) First Name Last Name Email * Phone * (###) ### #### Shipping Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Service Requested * Weight Loss Management Vitamins, Peptides, Lipotropics Allergies * Medication Information * Please list name and current dose of medication How are you tolerating your medication? * Any side effects? Medication Plan I would like to discuss a higher dosage. I would like to discuss switching to a new medication I am happy with my dosage and results I would like to discuss adding Lipo MICC or Lipo Mino Mix C I would like to discuss adding Phentermine, Diethyproprion , Contrave, Qsymia, or another weight loss medication not listed Diet * Are you eating your weight in protein? How much protein are you eating daily? Water Intake * How much water are you drinking daily? Exercise * How many days a week do you exercise? Are you lifting weights? Weight Information * Please list your starting weight Current Weight * Please list your current weight Since your last appointment, have there been any new changes? New medications, diagnosis, or surgeries since your last visit with 3-Peat Wellness? * List any new medications, diagnosis, or surgeries since your last visit with us Update your goal for the next month here? * List your goals for the next month here. Is it more weight loss, more energy, better sleep, more exercise, etc Any Concerns? * Are you ready to place an order for your medication within the next 3-5 days? * Yes Within the next 3 business days, When she would we try to call you? * 11:45am-12:45pm 6:00pm- 7:00pm Thank You For Being A Valued Client! Way to Champion Your Health! We will contact you within the next 3 Business Days. (Mon-Friday) Thank you!501-536-7909 or 501-499-9839
