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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
*
Submit
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.
Submit
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).
Submit
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