This form is for current RW Balance patients only, refilling something Dr. Smith has already approved. New here? Start an assessment instead.

For existing patients

Request your refill

Tell us what you're refilling and we'll ask the right follow-up questions. Dr. Smith reviews every refill request personally before it's approved.

What are you refilling? Select all that apply.

GLP-1 refill details

Starting weight (lb)

Current weight (lb)

Medication

Current dose

Do you feel the medication has been curbing your appetite?

Are you experiencing any of these side effects?

Peptide / NAD+ refill details

Which peptide are you refilling?

Current dose

How has your dose progression gone?

Any side effects since your last fill?

Hormone therapy refill details

Current prescription

Current dose

How is your dose progression going?

Any side effects since your last fill?

Have you had follow-up labs since starting?

Need another vial of bacteriostatic water? ($7)

Need more injection supplies? (syringes, alcohol swab pads)

Need an additional needle cutter? ($6)

Any changes to your health, medications, or allergies since your last visit?

Anything else your provider should know?

First name

Last name

Date of birth

Phone

How would you like to receive your order?

If you choose shipping, the flat $10 is added to your invoice after approval.

Mailing address

Refill requests are reviewed within 24-48 hours. No payment is collected now. Once approved, you'll receive an invoice, we'll order your product on payment, and it's typically ready for pickup or shipped within 7-10 days.

Questions? Email [email protected] or text 480-470-0493

Request received

You're all set.

Dr. Smith will review your refill request within 24-48 hours.

Once approved, you'll receive an invoice by email. We order your product as soon as it's paid, and it's typically ready for pickup or shipped within 7-10 days of that.

See tips for your best results

Questions? Email [email protected] or text 480-470-0493