Reverse Billing Request Form

Patient Request Form
Date of Request
Name

First NameLast Name
Email
example@example.com
Please describe your billing issue or concern:
Since your last order, how are you feeling? (scale 1–5)
Prescription refill or medication questionLab request or results discussionProtocol question or dosing clarificationNew symptom or issue to reviewPortal or technical supportGeneral check-in or follow-upOther (please describe above)
TRTHRTWeight LossNo Program, Single Order
EmailSMSPhone Call (Will be scheduled by Text)
Look into tracking for a recent shipmentProvide an itemized invoice or receiptContact pharmacy on your behalfConnect you directly with the pharmacyOther
Attach screenshot of billing issue or pharmacy message (optional)

Cancelof
Additonal Questions For Liaison/Dr. Rucker
Should be Empty:

Patient Request Form