Supplement or Injection Order Request (for Pickup or Refill)
Purpose: Lets current patients request a refill of a supplement or injectable (like B12, MICC, or glutathione) and lets you pre-approve or deny based on last dose, payment, or medical review.
Full Name
*
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Are You An Existing Patient At Brad-Rich? (*If not, Please call our office to schedule a consultation before requesting a product.*)
Yes
No
What Are You Requesting Today?
MICC Injection
B12 Injection
Glutathione Injection
CoQ10 Injection
Lipo-C
Vitamin D
Other
How would you like to receive it?
In-Clinic Injection
Pick-Up Supplement
Add to next scheduled appointment
Not sure / Please contact me
When was your last dose (If Known)?
-
Month
-
Day
Year
Date
Do you have any new health concerns or changes since your last visit?
Preferred Day/time for Pickup or Visit
Optional notes or Questions
Submit my request
Should be Empty: