What would you like
to refill or add?

Hello Gorgeous Medical Spa — We Screen You Like A Medical Practice Because We Are One. Pick a protocol, see patient pricing, and complete screening. Ryan reviews every request. Red-flag answers trigger a clinical hold.

Your request

Refill an existing protocol, or ask to add something new.

Protocol / SKU *

Identity & Compliance

Required for chart matching and safe dispensing.

Full Name *DOB *Phone *Email *Form requesting refill *Strength / dose currently using *How stored?Missed doses last 2 weeks?Reconstitution date (if applicable)Requesting early? Why?

Indication & Response

Helps us confirm continued benefit.

Original goal / symptom for this medication *Exact % (0-100)

0% No change50%100% Resolved

First noticed benefit *What makes better / worseRe-injury, new injury, surgery, change in activity since last fill?

Safety Stop Light

Yes/No — If Yes, details required. Any Yes = clinical review.

Nausea, flushing, dizziness, headache, palpitations?

Swelling at injection site, rash, joint pain, mood change?

ER visit, hospitalization, new diagnosis since last fill?

New allergies or reaction?

Infection, fever, illness last 7 days?

Any other side effects

Medical Update

Changes since last fill affect safety.

New medical conditions?

Pregnant / TTC / breastfeeding? *Weight change?Alcohol per weekNew medications / supplements / peptides? * Include blood thinners, NSAIDs, steroids, other peptides, hormone therapyTaking exactly as directed or changed dose/frequency on own? *

Goals & Consent

Final attestation required.

Goal for next cycle *Questions for provider

I understand this medication is prescribed only if a licensed Illinois clinician decides it is appropriate. Compounded medications are not FDA-approved for this indication. Long-term risks may not be fully known. I am requesting review voluntarily.

Signature * Full legal name

By submitting you confirm information is accurate. Clinical team will review within 1 business day. If red flags present, refill may be held.

Live Screening Summary

Client

Request · No protocol yet

Improvement 50%

Adherence —

Red Flags Detected

None yet

SMS Deliverable

hellogorgeousmedspa.com/regen/refill

Short URL + native SMS composer. iOS/Android opens Messages.

Admin · All Refills

Client	Protocol	Intent	%	Flags
No requests yet. Submit to populate dashboard.