Your name Your email Your Phone Subject Current PatientReturning PatientNew Patient Do you need a Refill of your medication? YesNo Do you experience Side any Effects? YesNo Please check any side effects that you may have. Abdominal PainNauseaVomitingConstipationRashDizzinessInjection Site ReactionOthers (Please write on message box) Requested Medication Tirzepatide-Not AvailableSemaglutide-Limited Supply What is your Current Dosage 4mg/dose7-9mg/dose120-140mg/doseI'm not sure What is your Current Dosage 0.5mg/dose1mg/dose1.75mg/dose2.5mg/doseI'm not sure Requested Dosage Same DoseNext Lower DoseNext Higher Dose Requested Medication Tirzepatide-Not AvailableSemaglutide-Limited Supply What is your Current Dosage 4mg/dose7-9mg/dose120-140mg/doseI'm not sure What is your Current Dosage 0.5mg/dose1mg/dose1.75mg/dose2.5mg/doseI'm not sure Requested Dosage Same DoseNext Lower DoseNext Higher Dose Payment Give me a Call, I will Pay via Card through PhoneI will visit the Office and Pay in Person Your message (optional)
