Hormone Replacement REFILL
Please complete this form in its entirety to process your refill request.
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What medication do you need refilled? Include your current dose:
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Date you completed your labs: (refills will not be processed without recent labs)
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Month
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Day
Year
Date
Date of last consult: (consults required every 3-6 months per provider discretion, please schedule a consult if you are due)
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Month
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Day
Year
Date
Please list any new medications or medication changes: ("n/a" if not applicable)
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Please list any new medical issues: ("n/a" if not applicable)
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Refill Policies: (please acknowledge each item)
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I understand that services/medications must be paid for before we order any medication.
I will not get testosterone from another provider while I am treating with CMW, or my refill will be refused.
Health insurance typically does not cover services provided at Combat Medic Wellness. If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.
Testosterone is considered a controlled substance. I agree that I will take my medications as prescribed. I also agree that I will not sell or share my prescriptions to other individuals.
I understand that there are NO REFUNDS for services or products rendered. We cannot accept used medications once they have been dispensed per state regulation.
I understand that I must maintain my follow up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. I UNDERSTAND THAT IF I FAIL TO GET MY LABS DONE BEFORE I NEED MORE MEDICATION, I WILL NOT BE PROVIDED WITH A REFILL UNTIL THEY ARE COMPLETE.
Patient Signature
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Submit
Should be Empty: