Emerge Wellness - WASHINGTONPatient Re-Fill Request Form Emerge WashingtonRe-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 (###) ### #### What is your current height & weight? * Required for monthly check-ins to ensure best practice is followed. What dose are you CURRENTLY on? * Choose medication below! I do not know my dose! 0.1mg Sema 0.2mg Sema 0.4mg Sema 0.8mg Sema 1.4mg Sema 1.5mg Sema 2.15mg Sema 2.7mg Sema 1.25mg Tirz 2.125mg Tirz 4.25mg Tirz 6.375mg Tirz 8.5mg Tirz 11mg Tirz 13.5mg Tirz 17mg Tirz None of these! What dose do you want to REFILL? * Choose medication below! 0.1mg Sema 0.2mg Sema 0.4mg Sema 0.8mg Sema 1.4mg Sema 1.5mg Sema 2.15mg Sema 2.7mg Sema 1.25mg Tirz 2.125mg Tirz 4.25mg Tirz 6.375mg Tirz 8.5mg Tirz 11mg Tirz 13.5mg Tirz 17mg Tirz None of these! What would you like to compound your medication with? * B6 (Nausea) B12 (Boost Metabolism & Energy) Please share how you're feeling. * Do you need a provider follow-up scheduled? * Yes No Which way to pay? Payments are required before we can process your refill! 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! 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 checkout! 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
