Free printable GLP-1 template
GLP-1 Refill & Injection Log Template
Use this free printable template to organize GLP-1 prescription, pharmacy, refill, supply, and injection records in one place.
No sign-upPrint-readyOptional iPhone reminders
Keep pharmacy and injection records together
Copy prescription details from the current label, note each pharmacy contact, and record each injection. See what has been filled, what remains, and which follow-ups are still pending.
Prescription and pharmacy details
Copy details exactly from the current label or pharmacy record.
Medication name and strength
Prescription number
Prescriber and phone
Pharmacy and phone
Date filled
Quantity / devices received
Refills remaining on label
Product expiration date
Prior authorization expiration, if applicable
Medication Guide received: yes / no / unsure
Refill contact log
Record dates, status updates, and next actions from each contact.
| Contact date | Pharmacy / insurer status | Pickup or delivery date | Quantity received | Question / follow-up |
|---|---|---|---|---|
Injection record
Record each injection with its medication, dose, site, and remaining supply.
| Date & time | Medication / strength | Dose from label | Taken / skipped / unsure | Site | Devices left | Notes |
|---|---|---|---|---|---|---|
Questions for your pharmacist or clinician
- Have any label instructions changed?
- How should this specific product be stored?
- What should I do if a device appears damaged or does not work as expected?
- Who should I contact about a missed or uncertain dose?
- Is any refill, coverage, or authorization action still pending?
My question
Answer / next action