Important Notice: This is a patient coordination and referral service. All requests are reviewed by a licensed physician at General Physician Network (GPN), a medical clinic. We are not a pharmacy. Approval is not guaranteed and is subject to full medical review and regulatory compliance. We do not prescribe or dispense medications.

ONLINE REFILLS PATIENT COORDINATOR

Patient Intake Form

Please complete the short form below. This helps our coordination team understand your needs and determine if we can assist you. All information is encrypted and kept strictly confidential.

1
Personal Info
2
Service
3
Details
1

Personal Information

2

Service Requested

Select the category that best describes the assistance you are seeking:

3

Medication Details

e.g. Phentermine, Alprazolam, Ambien, Semaglutide, etc.

Share anything else that may help our team understand your situation.

Your submission is encrypted and reviewed confidentially by our team. We typically respond within 1–2 business days.

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