GLP-1 Refill Form Template
A structured follow-up form for existing GLP-1 patients requesting a prescription refill. Captures current biometrics, injection history, recent health changes, and any new medications or surgeries since the last visit. Designed to give prescribers the clinical context needed to safely renew GLP-1 prescriptions and adjust dosing as needed.
Free Template
GLP-1 Refill Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
GLP-1 Refill Form
1 Current Biometrics
Please provide your most recent measurements.
Current Biometrics
Please provide your most recent measurements.
What is your current height (in inches)?
e.g. 68
What is your current weight (in pounds)?
e.g. 210
2 Injection History
Tell us about your recent GLP-1 use.
Injection History
Tell us about your recent GLP-1 use.
Are you actively taking or have you recently taken any GLP-1 medications?
If yes, when was your last injection date?
—
If yes, how many units was your last injection?
e.g. 0.25
If yes, how many months have you been taking GLP-1 medications?
e.g. 3
3 Health Changes
Please let us know about any changes to your health since your last visit.
Health Changes
Please let us know about any changes to your health since your last visit.
Since we last saw you, have you started any new medications, had any surgeries, or had any significant changes to your health?
If yes, please share the details.
Describe any new medications, surgeries, or health changes...
Is there anything else the practitioner should be made aware of?
If yes, please share the details.
Any additional information for your provider...
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
GLP-1 refill prescriptions require documented follow-up evaluation. Prescribers should review weight change since last visit, any new contraindications, and adverse event history before renewing. See FDA semaglutide labeling: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/215256s000lbl.pdf
New medications reported since last visit should be screened for interactions, particularly insulin, sulfonylureas, and other glucose-lowering agents which can increase hypoglycemia risk when combined with GLP-1 agonists.
Want This Form Automated?
Karpa Health turns static intake forms into a fully automated clinical workflow. Branded, HIPAA-compliant, and connected to compounding pharmacies.
- Branded intake on your website
- AI contraindication screening
- One-click prescribing to pharmacies
- Automated refill management
- E-signatures and HIPAA audit trail
- 50-state provider network included
Free 30-minute walkthrough
Sources & References
Frequently Asked Questions
How often should GLP-1 patients complete a refill form?
A follow-up form should be completed at each refill visit, typically every 4 to 12 weeks depending on the program structure. Regular check-ins allow prescribers to monitor weight progress, adjust dosing, and identify any new health changes or drug interactions.
What triggers a full intake instead of a refill form?
If a patient reports new medications, surgeries, significant health changes, or has been off therapy for more than 90 days, a full intake form should be completed in place of the refill form to ensure no new contraindications have developed.