BACD Rx Refill Request Form

Please note we are only able to process a BACD Rx topical product refill via this form if:

you have an active prescription from a BACD provider AND
you have a credit card on file with our clinic.

If we do not have a credit card on file for you, please call our office during business hours: 415-292-6350 (M-F, 8AM- 5PM). Press 2 to be directly connected to our product concierge team.

If we are unable to confirm the prescription with your provider, we will reach out to you directly using the contact information you provide below.

Your Name*

First NameLast Name

Date of Birth*

Date

Your Phone Number*

Please enter a valid phone number.

Please select the BACD Rx topical product you would like refilled.

To select more than one product, hold down the CTRL or COMMAND button.

Please select the BACD Rx topical product you would like refilled as well indicate quantity desired. We are unable to fulfill more than 3 of any item at a time.*

	Quanity
10% Tranexamic Acid Cream
4% Melasma Combo Emulsion
Acne Combo Gel
Acne Dapsone Gel
AK Cream
Alopecia Topical Solution Men
Alopecia Topical Solution Women
Antibacterial Wound Petrolatum Ointment
Azelaic Cream
Brightening Lotion (Discontinued)
Brightening Pads
Dermatitis Cream with Clobetasol
Gentle Tretinoin [120 ml]
Rosacea Combo Gel
Seborrheic Dermatitis Shampoo
Sulfur Wash
Tretinoin 0.05% Gel

BACD Brightening Pads Notice:

Please be advised our Brightening Pads range in price from $113-$233 dependent on which strength (2-12% hydroquinone) your BACD provider recommends for you.

Before shipping your product, we confirm the product strength with your provider. If you would like to know the specific percentage and correlating price before purchasing, please first email our product concierge team: shop@weloveskin.com.

Do you have a We Love Skin Club discount code? Enter the code below and we'll apply it to your order!

Example: JBTGIN22

Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Email*

example@example.com

Signature*

BACD RX Topical Product Refill Request

Please note we are only able to process a BACD Rx topical product refill via this form if: