Emerge Wellness - IDAHO - Patient Re-Fill Request Form Emerge IDAHO GLP/GIP 4 WEEK PRICING PLANRe-Fill Request Form Patient Info: 💉 Medication comes in 4 prefilled syringes for our 4-week dosing option. MEMBERS please keep scrolling to form below on smart phone or to your right on a desktop. First Name Last Name Date of Birth * Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### What is your current height & weight? * Required for monthly check-ins to ensure best practice is followed. What dose are you CURRENLTY on? * 2.5mg Tirz/B6 5mg Tirz/B6 7.5mg Tirz/B6 10mg Tirz/B6 12.5mg Tirz/B6 15mg Tirz/B6 0.25mg Sema/B12 0.50mg Sema/B12 1mg Sema/B12 1.5mg Sema/B12 2mg Sema/B12 2.5mg Sema/B12 None of These! What dose do you want to REFILL? * 2.5mg Tirz/B6 5mg Tirz/B6 7.5mg Tirz/B6 10mg Tirz/B6 12.5mg Tirz/B6 15mg Tirz/B6 0.25mg Sema/B12 0.50mg Sema/B12 1mg Sema/B12 1.5mg Sema/B12 2mg Sema/B12 2.5mg Sema/B12 Please share how you're feeling and if we need to increase, decrease, maintain, or adjust your current dose. * Need to increase - have you plateaued? Need to decrease - having side effects? Do you need a provider follow-up scheduled? * YES NO Which way do you want to pay? * Payments are required before we can process your refill! CASH INVOICE IN SIMPLE PRACTICE PLEASE ALREADY PAID FOR SERVICE IN SQUARE SPACE! Are you a previous Enriched Health patient? $200 Semaglutide until 1/1/26 YES - I was a patient of Emily's before Emerge Wellness NO - I started with Emerge Wellness Discount Eligibility Please check any that apply to you so we can apply your discount at time of processing. I am on Hormone Therapy (HRT) w/ Emerge Wellness: 15% off Peptides & GLP I am on a GLP Membership w/ Emerge Wellness: 15% off Vitamins & Infusions I am a member of 208 Jiu Jitsu: 15% off Vitamins & Infusions I am a client of EVLO Salon: 15% off Vitamins & Infusions I was referred by Rest Sweat: $25 off first service Comments/questions? Our team will get back to you within 24-48 hours. Thank you for choosing Emerge Wellness!We’ve received your submission and will be in touch shortly.If you need immediate assistance, feel free to call or text our business line at: 208-417-3775 Emerge IDAHO MEMBERSIP Re-Fill Request Form Patient Info: * ONLY proceed if you are a member who has signed up for a Tier Membership and is charged monthly. Otherwise please fill out the form to the left, OR purchase directly by selecting 'GLP/GIP 4 Week Pricing Plans' First Name Last Name Date of Birth * Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### What is your current height & weight? * Required for monthly check-ins to ensure best practice is followed. Which membership are you on? * If you want to increase your dose outside the Teir amount, we will reach out to you to sign up for the next Tier Membership. Sema - Mirco Dose Sema Tier 1 (0.50mg - 1mg) Sema Tier 2 (1.5mg - 2.5mg) Tirz Tier 1 (2.5mg - 5mg) Tirz Tier 1 (7.5mg - 10mg) Tirz Tier 1 (12.5mg - 15mg) What dose are you CURRENTLY on? * 0.25mg Sema 0.50mg Sema 0.75mg Sema 1mg Sema 1.5mg Sema 2mg Sema 2.5mg Tirz 5mg Tirz 7.5mg Tirz 10mg Tirz 12.5mg Tirz 15mg Tirz None of Theses! Being on a Membership, you may choose to compound your medication with NAD+, B12, or B6. Please let us know which you prefer below. This can be changed every re-refill if preferred. NAD+ (Improve Cognitive Function) B12 (Boost Metabolism & Energy) B6 (Nausea) Would you like to decrease your dose, increase your dose or remain the same? If you would like to switch all together please select yes to a provider follow-up! INCREASE DECREASE REMAIN THE SAME BOOK ME A FOLLOW UP WITH DANIELLE, NP Is there anything you would like us to know? * Which way did you want to pay? * Payments are required before we can process your refill! CASH ALREADY PAID FOR SERVICE IN SQUARE SPACE! Are you a previous Enriched Health patient? $200 Semaglutide until 1/1/26 YES - I was a patient of Emily's before Emerge Wellness NO - I started with Emerge Wellness Discount Eligibility Please check any that apply to you so we can apply your discount at time of processing. I am on Hormone Therapy (HRT) w/ Emerge Wellness: 15% off Peptides & GLP I am on a GLP Membership w/ Emerge Wellness: 15% off Vitamins & Infusions I am a member of 208 Jiu Jitsu: 15% off Vitamins & Infusions I am a client of EVLO Salon: 15% off Vitamins & Infusions I was referred by Rest Sweat: $25 off first service Comments/questions? Our team will get back to you within 24-48 hours. Thank you for choosing Emerge Wellness!We’ve received your submission and will be in touch shortly.If you need immediate assistance, feel free to call or text our business line at: 208-417-3775