Prescription Refill Form

First Name *

Last Name *

Date of birth *

Phone *

Current Weight *

Goal Weight *

Are you within 10 lbs of your goal weight? *

Have you taken more than a 10 day break since your last injection? *

What was the date of your last shot? *

How many units or milligrams did you inject on the date of your last shot? *

Do you feel the medication is working for you? *

Do you feel we need to increase the dose? As a general rule for Wegovy/Semaglutide, we go up on the dose every month until reaching a goal dose of 2.4 mg. For Mounjaro/Zepbound (Tirzepatide), we go up every month until we reach a goal of 15mg *

Are you currently pregnant, nursing, or have plans to get pregnant in the next 2 months? *

Optional-Any other side effects or concerns you want to discuss with the doctor?