Revive-ify Wellness — Medication Refill Request Form

Revive-ify Wellness — Medication Refill Request Form
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone*
Email*
Medication Details
Medication Name: (Note: the same quantity of medication will be ordered unless otherwise specified)*
Have you experienced any side effects or changes in your health since your last refill?

NoYes
If yes, please provide details:
Shipping Address:*
Refill Policy Acknowledgment
Please read carefully and check the box to proceed:*

I understand that submitting this request does not guarantee a refill. My provider will review my chart to ensure my refill is appropriate and safe.I understand that prescription refills are typically processed and ordered within 1–2 business days of approval and that delivery from the pharmacy may take 7–10 business days.I understand I will receive an email confirmation once my refill has been processed and submitted to the pharmacy.
Payment Authorization
Please read carefully and check the box to proceed:*

I authorize Revivify Wellness to charge the payment method entered below for any applicable medication refill costs. I understand that refill requests are subject to a $35 refill fee, which will be charged upon completion of this refill request. I agree that my refill will not be processed until payment has been collected.
Provider Communication
Please read carefully and check the box to proceed:

I would like my provider to contact me to discuss my treatment plan or dosing adjustments. (Note: If your provider determines that additional discussion is needed to ensure your safety, you will be contacted before your refill is processed.)I do not have any dosing or medication questions at this time.
Need to Book a Follow-Up?
If you’d like to review your treatment plan, discuss dosing adjustments, or talk about adding peptides or supplements:

You can schedule a follow-up appointment anytime through your Revivify Wellness Patient Portal.

Credit Card Details *

Refill Processing Fee

$35.00 Quantity

Total

$0.00

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

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email for Receipt*
example@example.com
Signature*

Clear
Signature and payment are completed electronically on the next screen.
Should be Empty:

Revive-ify Wellness — Medication Refill Request Form

Patient Information

Medication Details

Refill Policy Acknowledgment

Payment Authorization

Provider Communication

Need to Book a Follow-Up?