Prescription Refill Request Form

Prescription Refill Request Form

Welcome! You’re in the right place for a quick prescription refill between visits. The $50 fee covers review and efficient processing of your request. Need a new prescription or a tweak to your treatment plan? Book a Progress Visit here (link).

Please complete every field accurately. After you submit, we’ll send you a confirmation email and start your refill right away.
Patient Information
Name

First NameLast Name
Email
example@example.com
Prescription Delivery method

Email the prescription to meFax the prescription to my pharmacy

Pharmacy Information
Pharmacy name
Pharmacy address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy fax number
Please enter a valid phone number.

Prescription Details
Prescriptions*

Payment

My Products*

Prescription RefillKeep your treatment moving smoothly with a hassle-free prescription refill. The $50 charge covers the review and processing of your prescription refill.

$50.00CAD Quantity

Total

$0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Prescription Refill Request Form

Patient Information

Pharmacy Information

Prescription Details

Payment