Date *

MM

DD

YYYY

Client Information *

Prescription Refill Request and Follow Up Form. Please fill this form out when you are ready to order your next month of medication.

First Name

Last Name

Phone *

(###)

###

####

Shipping Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Service Requested *

Weight Loss Management

Vitamins, Peptides, Lipotropics

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

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 3 days? *

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

Yes