Order Refills

THE VIKING OFFICE WILL RECEIVE AND EVALUATE YOUR REFILL REQUEST. IF APPROVED, THE PAYMENT INFORMATION SPECIFIED WILL BE CHARGED AND THE ORDER PROCESSED AND SUBMITTED TO THE PHARMACY.
Date
MM slash DD slash YYYY
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Email*
Enter Email Confirm Email
Phone*
Drivers License Number
State
Which Medications do you want to reorder.*
Note: If a medication is outside of your already approved protocol you will need to schedule a consultation before we can send any new medication. ALSO: It is required that your lab results be less than 6 months old at all times. Please schedule labs prior to refill order if needed!
Shipping Address*
***We cannot ship to a PO Box - we need an actual street address in order to ship your medication. ***

Street Address Address Line 2 City State ZIP Code
Is your shipping address the same as billing address?*
- Yes
- No
Billing Address
Street Address Address Line 2 City State ZIP Code
Pay with Cryptocurrency
- YES
- NO
Cardholder's Name
Credit Card
Card Type
- American Express
- Discover
- Mastercard
- Visa
- HSA
Expiration Date
Expiration Year
Security Code

New Patient Form

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Schedule Your Consultation

Order Refills

THE VIKING OFFICE WILL RECEIVE AND EVALUATE YOUR REFILL REQUEST. IF APPROVED, THE PAYMENT INFORMATION SPECIFIED WILL BE CHARGED AND THE ORDER PROCESSED AND SUBMITTED TO THE PHARMACY.