MED-FIT PRESCRIPTION REFILL REQUEST FORM

Full Name *

Phone *

Email *

Patient DOB *

Current Weight *

PHARMACY - Please specify which location *

Address

Compounded Semaglutide or Compounded Tirzepatide patients ONLY: Please confirm your prescription mailing address.

City

State

Postal code

MEDICATION REFILL REQUEST (Please include MG if possible) *

Any issues or side effects that we should be aware of?

Any new allergies?

I Consent to Receive SMS Notifications and Alerts from Med-Fit Medical Weight Loss regarding my prescription refills. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

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PLEASE ALLOW 72 HOURS FOR REQUESTS ON ALL CURRENT MEDICATIONS.

AN APPOINTMENT AY BE REQUIRED.

PRESCRIPTION REFILL REQUESTS WILL BE SUBMITTED TO MED-FIT MEDICAL WEIGHT LOSS