Express Health Systems Refill Request

Refill Request

EXPRESS HEALTH SYSTEMS

Refill requests only approved for more than 1 month purchases.
Submit request at least 3-5 days before you are out of medication.
Requests will only be approved if it has been 30 days from your last refill.
Allow up to 48 hours for refills to be processed.
Refills requested on the weekend will be returned to the pharmacy by Monday, 5pm CST.
After careful consideration and evaluation of our needs, we regret to inform the public that we are unable to continue using Walmart, Walgreens, CVS, or Kroger for our services.

Patient Name *

First Name (as appears on License/Identification)

Last Name (as appears on License/Identification)

Date of Birth *

Biological Sex * Female Male

Email Address *

Please enter your blood pressure as of today: *

Systolic

Diastolic

Heart Rate: *

Weight *

Waist and Hip Circumference (inches): *

Waist

Hip

Pharmacy Change (if needed):

Pharmacy State *

By requesting prescription medication treatment I hereby give EHS permission to share relevant medical information, including Visit assessment(s), to my selected pharmacy as my EHS clinician deems appropriate and/or based on a request from my selected pharmacy.

Medication Name and Dose *

Acknowledgement

By clicking this box, I am declaring that I am not currently receiving, nor will I seek to obtain, appetite suppressants from any other health care provider or from any other individual(s) while I am receiving appetite suppressants from Express Health Systems (EHS). Additionally, I declare that I am not currently taking, nor will I seek to obtain, any ADHD medications, such as Adderall (dextroamphetamine + amphetamine), Ritalin (methylphenidate), Methylin (methylphenidate), Focalin (dexmethyphenidate), Dexedrine (dextroamphetamine), or Zenzedi (dextroamphetamine) while receiving appetite suppressants from EHS. I am declaring that I agree to take all prescription medications as prescribed by the medical provider that provided the prescription. I declare that I am not abusing any prescription medications or using any illicit drugs.

By clicking this box, I am declaring that I am not experiencing any significant adverse reactions to any medications that I am taking that were prescribed to me by Express Health Systems.

By clicking this box I am declaring that weight management lifestyle changes, behavioral modifications, and exercise have failed to provide me with significant and/or longstanding weight reduction to a healthy weight; therefore, I am requesting medical weight management, including prescription medication(s). I do not have any history of adverse effects from previous and/or current medical weight management, including prescription medication(s). I declare that I am aware that my educational materials from EHS are available from EHS' Patient Portal (portal.exphs.com), that I am to review them, and that I agree to attempt to implement the recommendations found therein.

All the above boxes must be true and verified by selecting them or the refill request cannot be submitted. All the above boxes are to be selected (if true) regardless of one's gender or age. If the above questions are not true and confirmation of their truth cannot be attested to honestly then you must not submit this refill request. Under those circumstances you will need to make an appointment to be evaluated by an Express Health Systems' clinician.