Patient initials* Due to insurance regulations, any Primary Care patient prescribed compounding medication(s) will be required to see Dr. Veerula as a Cash Pay patient.Patient initials* There will be an Office Visit fee of $175 (Existing patient) or $225 (New patient).Effective immediately, we will no longer honor pharmacy refill requests. This is due to the increasing discrepancies from several pharmacies. This includes all pharmacies retail and compounding. The refill request applies to both Primary and Integrative Medicine patients.If a refill is required, the patient must contact our office directly. Please note some refills will require an office visit.We apologize for any inconvenience. Date: Date* Patient Name: First Name* Last Name* Patient Signature: Signature*