Patient Intake Form – Online Refills

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

State of Residence *

Preferred Contact Method(s) * (select all that apply)

Please select the ways you would like us to contact you. You can choose more than one.

Phone CallPhone Email Text / SMSSMS WhatsApp Signal Telegram

Service Requested

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

Weight Loss Support

Prescription weight management medications

Anxiety & Mental Health Support

Anxiety, stress, and related mental wellness medications

Pain Management

Chronic or acute pain medication coordination

Sleep Support

Sleep aid and insomnia medication assistance

Other

Please describe in the details section below

Medication Details

Please specify the medication you are seeking assistance with *

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

Have you been prescribed this medication in the past by a doctor in person? *

Yes No

I understand that Online Refills is a referral facilitation service, not a pharmacy or medical provider. I acknowledge that submitting this form does not guarantee a prescription, refill approval, or any medical outcome. I consent to being contacted by the Online Refills coordination team regarding my inquiry, and I confirm that the information I have provided is accurate and truthful. *

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