Date *

MM

DD

YYYY

Client Information *

Prescription Refill Request and Follow Up Form. You can also message us your prescription request through the patient portal.

First Name

Last Name

Phone *

(###)

###

####

Shipping Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Service Requested *

Weight Loss Management

Vitamin Injections

Men's Testosterone Replacement

Women's Bioidentical Hormone Replacement

Longevity Therapy

Medication Plan *

I am happy with my dosage and results

I would like to discuss a higher dosage.

I would like to discuss switching to a new medication

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

I would like to discuss adding NAD+

I would like to discuss adding Peptides (Sermorelin)

I would like to discuss Hormone Replacement Therapy

Would you like to continue your current medication and dose? *

Yes, continue my current medication and dose

No, I need you to make some changes

Are you ready to place an order for your medication within the next 10 days? *

If you need more time, please wait and fill this form out when you are ready to place an order.

Yes

Clinic Policies *

We currently do not accept Medicare Clients. Health insurance typically does not cover services provided at 3-Peat Wellness. If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company. For payments options we do accept pay pal, debit cards, after pay, klarna, major credit cards, FSA or HSA cards for payment. If your FSA/HSA is later denied, this will be your responsibility. I understand that treatments used at 3-Peat Wellness might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional and supplemental counseling, and weight loss treatment. I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.

I agree