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DIRECT PRIMARY CARE REFILL REQUEST

HORMONE REFILLS

WEIGHT MANAGEMENT

PRIMARY CARE REFILL REQUEST

First name*

Last name*

Birthday*

Month

Day

Year

Email*

Phone*

Primary Care Pharmacy (store name, city, street or intersection - i.e. "CVS in Blue Springs at Moreland Ridge and 7 HWY")

Medication(s) requested - please denote if you prefer 30-day or 90-day prescription for each*

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HORMONE THERAPY REFILL REQUEST

PRIMARY CARE REFILLS

WEIGHT MANAGEMENT

HORMONE REFILL REQUEST

First name*

Last name*

Email*

Phone*

Testosterone Dose:

Estrogen blocker (i.e. anastrozole)?

Estradiol Dose:

Progesterone Dose:

Additives, comments, questions, requests, etc.

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WEIGHT MANAGEMENT REFILL REQUEST

PRIMARY CARE REFILLS

HORMONE REFILLS

WEIGHT MANAGEMENT REFILL REQUEST

First name*

Last name*

Email*

Phone*

Refills requested:

Metformin

Phentermine

Low-dose Naltrexone

Topiramate

Skinny shot(s)

Semaglutide

Tirzepatide

Other

Enter dosages and details (30-days, 90-days, 4 injections, one vial, etc).

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Email*

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ADDRESS:

801 Northwest Saint Mary Drive

Suite 210

Blue Springs, MO 64014

CONTACT:

(816) 200-1533

Virtue@VirtueMedKC.com

Virtue Medical

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