Medication Refill Request

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Thank you for submitting your request. We will reach out if we need anything further.

First Name

Last Name

Date Of Birth (YYYY-MM-DD)

Beginning Weight

Current Weight

What medication are you using?

Have you had any side effects?

How many units are you using?

What lifestyle changes are you making?

What changes are you making to sustain your weight loss?

Do you want to reorder medication?(required)
If no, please notify me at 317-873-5509 to reorder your medication or if you would like to stop your weight loss visits.

Yes, order and charge my credit card on file. I understand to allow 7-10 Business days for delivery No, I do not want to order medication at this time. I will notify when medication is needed. I understand I should allow 7-10 Business days for delivery.

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MEMBERSHIP REMINDERS

Remember, 1 Monthly InBody scan is included in your monthly membership! These are optional, however highly recommended to accurately track progress and body composition.

Please be advised that while you are being prescribed medication, you will be charged $79/month oversight fee. It is the patient’s responsibility to order medication as needed and are required to meet with the NP or RN if they are seeking dosage adjustments.

Using medications past the BUD (beyond use date) is discouraged. If your medication is injectable, it is encouraged to only order the volume of medication that can be used within 45-60 days of delivery.

You must notify your provider 7-10 days in advance for all address changes or requested shipping delays.