Refill Request Form

Date *

First Name *

Last Name *

Phone *

Email *

Date of birth *

Address

Shipping Address *

City

State

Country

Postal code

Medication(s) Requesting Refill On *

Are you requesting a change in dosing for this refill? *

Please notate the change of dosing you are requesting. (Example: I would like to move up to the next round of my weight loss medication).

Have you had any changes in your medical history since your last refill? *

Please input the last 4 digits of your card on file that you are authorizing to be charged for this refill. (If you are on a monthly autodraft GLP or TRT membership, please disregard).

If you answered yes to change in medical history, please schedule a quick Telehealth appt with the booking link below.

http://balanced.zenoti.com/webstoreNew/service