7730 Roswell Road #400
Sandy Springs, GA 30350

Tel: (678) 239-4046

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NATIONWIDE

Semaglutide for
SAFE and EFFECTIVE weight loss

Occupational Health Services
DOT Physicals | Drug Testing | Labs

Schedule Here

Prescription Refill Request

Elite Health Solutions Medication Refill Request

First name*

Last name*

Date of Birth*

Cell Phone with area code:

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

Current Medication:*

Semaglutide

Tirzepatide

Have you experienced any recent side effects:*

Severe nausea

Severe vomitting

Severe constipation

No side effects

Side effects: Please explain what you are experiencing in detail.

Weight Loss:*

I am still losing weight / inches

I have stalled at least 2 weeks in weight loss / inches lost

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)

Intial Sarting Weight (pounds)*

Current Weight (pounds)*

Refill Dosage Options:*

I would like to stay on current dose / units.

I would like to increase to the next dose / units.

I would like to discuss switching to another medcation (Semaglutide or Tirzepatide)

I understand that an increased dose does not mean greater weight loss. Patients should stay at their current dose if they are still losing weight / inches. If ALL nutrition and exercise is being followed, and no loss x 2 weeks a dose may be warranted.

Prescription refills require review from a licensed provider. Please indicate below which option you would like for your refill request review. Provider reserves the right to require a telehealth visit based on relevent clinical information required*

Telehealth appointment (scheduled) via live video with provider.

Review from provider WITHOUT a live teleheath appointment.

ADDRESS

7730 Roswell Road #400
Sandy Springs, GA 30350

Tel: (678) 239-4046

OPENING HOURS

Monday: 8:00am - 4:00pm

Tuesday - Thursday: 7:00am - 5:00pm

Friday: 8:00am - 3:00pm

Saturday: By Request / Availabliity

Sunday: Closed

*closed for all Federal Holidays*

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