*Requests on following page

Which medication(s) are you requesting to refill? Please list the name, strength, and current dosage *

Side effects or concerns, *

Yes

If yes, Please describe any side effects or concerns:

Is there anything additional you would like to improve or address in your treatment plan?

Have there been any changes to your medical history, diagnoses, or health status since your last order? *

Yes

If Yes, Please Explain:

Has your address changed since your last order? If yes, list new address below:

*Please allow 1-2 business days to process the order. Lab work must be within 5 months for refills to be processed