Weight Loss Medication Refill Request Form

Online Check-In &

Medication Refill Request Form

Welcome to Scrubd Esthetics! To streamline your visit and ensure the best care, please complete the form below before your appointment. If you need a medication refill, you may also request it here.

Patient Information

Name

Email Address

Phone Number

Date of Birth

Online Check-In & Refill Request

Appointment Date & Time

Service You’re Receiving

Current Weight (lbs)

Current Medications & Dosage

If so, please explain.

How much weight (lbs) have you lost since your last check-in?

Have you experienced any side effects?

How would you rate your ability to tolerate the medication?

Do you feel ready to continue with the same dose?

I confirm that the information provided is accurate to the best of my knowledge.

I acknowledge that medication refills are subject to provider approval and may require an appointment.

Thank you!
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