Current Weight Loss PatientReorder Medication Form Name * First Name Last Name DOB * MM DD YYYY Base Plan * Tirzepatide: Base Plan $575 (2 vials/40 mg, supplies, shipping) Semaglutide: Base Plan $575 (1 vial, 12.5 mg, supplies, shipping) Who is your provider? Brandon Kramer Shamus Reimold Frank Gargasz Kellianne Nerlich Christopher Katakowski Sara Pinkerton John Fenner, MHS, PA-C Any changes to your health history (past 6 months)? * Any new Medications (past 6 months)? * Current Weight: * Have you had a change of address since your last order? No Yes What is your new shipping address? Address 1 Address 2 City State/Province Zip/Postal Code Country Have you changed your credit card/payment card since your last order? Yes No Additional Comments * I approve the purchase of the above stated medications and give Revive Performance Medicine permission to charge the credit card on file for my account. Thank you!(your provider will review the request and contact you if there are any questions).
