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 StateChoose StateChoose your stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificWhich 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 ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPuerto RicoRISCSDTNTXUTVTVAWAWVWIWYAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan State ZIP Code Is your shipping address the same as billing address?* Yes No Billing Address Street Address Address Line 2 City ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPuerto RicoRISCSDTNTXUTVTVAWAWVWIWYAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan 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 Get Labs Schedule Your Consultation Order Refills