MONTHLY WEIGHT LOSS MEMBERSHIP PATIENTS ONLY

This refill request form is exclusively available to patients enrolled in the Igia Wellness & MedSpa Monthly Weight Loss Membership ($75/month). Membership must be active during submission.

PROVIDER DISCRETION & IN-PERSON APPOINTMENT DISCLAIMER:

This refill request form is provided as a courtesy service for active Monthly Weight Loss Membership patients. Submission of this form does not constitute a prescription, an approval, or a guarantee that a refill will be issued. The provider at Igia Wellness & MedSpa reserves the sole and absolute right to determine, at their clinical discretion, whether a refill via this form is medically appropriate. If the provider determines that an in-person or telehealth appointment is necessary before a refill can be safely prescribed, including but not limited to cases involving new or worsening side effects, safety concerns, lack of expected progress, new medical conditions, changes in medications, or any other clinical indication.

The patient will be notified and required to schedule an appointment prior to receiving a refill. Circumstances that will automatically trigger a required appointment include: severe or worsening side effects; any “Yes” answer in the Safety & Health Update (Section 6); request for a dose increase accompanied by active moderate-to-severe side effects; membership lapse or non-payment; or provider clinical judgment that a higher level of assessment is warranted. Igia Wellness & MedSpa is not liable for any delay in medication access resulting from the requirement for an in-person evaluation.