BACD Rx Refill Request Form

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BACD RX Topical Product Refill Request
Please note we are only able to process a BACD Rx topical product refill via this form if:
1. you have an active prescription from a BACD provider AND
2. 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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.

Rows	Quanity
10% Tranexamic Acid Cream
4% Melasma Combo Emulsion (KATARYA)
Acne Combo Gel (INZDEOXIA GEL)
Acne Dapsone Gel (DIASOXIA GEL)
AK Cream (QUIHOXAXIA GEL)
Alopecia Topical Solution Men (FINAPOD)
Alopecia Topical Solution Women (PODPROG)
Antibacterial Wound Petrolatum Ointment (BAXONIL)
Azelaic Cream (RUMILO CREAM)
Brightening Pads
Dermatitis Cream with Clobetasol (DIVINIX CREAM)
Gentle Tretinoin [120 ml] (ALURIS CREAM)
Precancer Cream (KEFUNOVA CREAM)
Rosacea Combo Gel (ROSITARA GEL)
Seborrheic Dermatitis Shampoo (DAFILOR SHAMPOO)
Sulfur Wash (APEXOL SUSPENSION CLEANSER)
Tretinoin 0.05% Gel (ALURIS 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
Should be Empty:

BACD RX Topical Product Refill Request

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