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Medication Refill Request
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Your request has been sent
Thank you for submitting your request. We will reach out if we need anything further.
First Name
*
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Last Name
*
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Email
*
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Date Of Birth (YYYY-MM-DD)
(required)
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Beginning Weight
(required)
This is the weight you started your journey
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Current Weight
(required)
This is the weight you just got from your scale
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What medication are you using?
(required)
Medication name
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Have you had any side effects?
(required)
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How many units are you using?
(required)
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What lifestyle changes are you making?
(required)
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What changes are you making to sustain your weight loss?
(required)
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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.
Warning
Message
Warning
By submitting this form, you confirm that you are a current patient under our care and that you are requesting a refill of previously prescribed weight loss medication. You acknowledge that continued use of this medication requires ongoing clinical oversight, and you consent to being contacted by our team if follow-up is needed prior to approval.
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