Emerge Wellness - WASHINGTON - Patient Re-Fill Request Form 4 WEEK DOSING COST Emerge WASHINGTON Re-Fill Request Form Name First Name Last Name Date of Birth Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number (###) ### #### Is this a TIER membership re-fill? * Our membership options can be selected at the top of the page and will automatically bill your card each month. You can request a new vial of medication at any time, and it can be compounded with B6, B12, or NAD+ based on your preference. Please note: this is not our 4-week dosing option with pre-filled syringes. Yes NO 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 None of these! What dose of medication do you want a refill of? Choose medication below! 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 None of these! Which way to pay? Payments are required at time of service! CASH INVOICE IN SIMPLE PRACTICE PLEASE ALREADY PAID FOR SERVICE IN SQUARE SPACE FOR MONTHLY ORDERING! ALREADY PAID FOR SERVICE IN SQUARE SPACE WITH MONTHLY MEMBERSHIP! Please share how you're feeling and whether we should consider increasing, decreasing, maintaining, or adjusting your current 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 - I was a patient of Emily's before Emerge Wellness NO - I started with Emerge Wellness Comments/questions? Our team will get back to you within 24-48 hours. What is your current weight? * Required for monthly check-ins to ensure best practice is followed. 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
