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Prescription Refill Request

Elite Health Solutions Medication Refill Request


Date of Birth

Patient acknowledges that Elite Health may send SMS text to this number regarding this refill request.

Current Medication:
Have you experienced any recent side effects:
Weight Loss:

A stall in weight loss:

No weight or inches lost x 2 weeks, and the following has been done daily:

  • appropriate caloric intake daily (not enough calories can cause a stall)

  • high protein diet, well balanced with low carb and healthy fats

    (0.5g - 1g of protein per day, per pound of body weight)

  • exercise at least 3 times per week (some additional movement)

Refill Dosage Options:
Prescription refills require review from a licensed provider. Please indicate below which option you would like for your refill request review.
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