Emerge Patient Re-Fill Request Form Name * First Name Last Name What dose of medication are you on? * Choose medication below! I do not know my dose! SEMAGLUTIDE .25 MG SEMAGLUTIDE .50 MG SEMAGLUTIDE .75 MG SEMAGLUTIDE 1 MG SEMAGLUTIDE 1.5 MG SEMAGLUTIDE 2 MG SEMAGLUTIDE 2.5 MG TIRZEPATIDE 2.5 MG TIRZEPATIDE 5 MG TIRZEPATIDE 7.5 MG TIRZEPATIDE 10 MG TIRZEPATIDE 12.5 MG TIRZEPATIDE 15 MG Which way to pay? * VENMO @Emily-Emerge Cash pay - schedule a clinic cash drop off under 'SCHEDULE' Please note we do not fill medication orders until invoices are paid. In rare cases we do make an exception. Please use our contact form to connect with us directly! CASH VENMO INVOICE PLEASE ALREADY PAID Date of Birth * Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Tell us how you are feeling and if we need to increase, decrease, stay the same or change dose. * Do you need a provider follow-up scheduled? * YES NO Are you a previous Enriched Health patient? * $200 Semaglutide until 1/1/26 YES NO 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