Refill Request and Information

Date
Date Format: MM slash DD slash YYYY
Name
First Last
Email
Enter Email Confirm Email
Phone
Divers 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
Cardholder's Name
Credit Card
Card Type
- American Express
- Discover
- Mastercard
- Visa
- HSA
Expiration Date
Expiration Year
Security Code

Information about Refills

Please submit the information requested in the form located on this page. Even though it seems like we are duplicating some of the information we ask for, we do need you to resubmit the in order to comply with all the rules!

Your labs must be less than 6 months old for us to be able to submit your request to the pharmacy. If your labs are older than 6 months you have some choices - you can schedule a quick consultation

Quick ConsultationIf you would prefer you can get an order for your labs and take it to the location of your choice by choosing our partner PrivateMD Labs.

The most common set of tests that you need is the package called " Hormones and Metabolism, Female Specific Tests, Infertility Testing" - yes, even for men. You can order the tests here:

Hormone panel 1The less common panel may be required depending on the medication you are prescribed. If you need this panel, you will be told to order the "Hormone Panel for Males", or Hormone panel 2:

Hormone panel 2For Women - you will be asked to order the ""Hormone Panel with E2 Sensitive, Progesterone & Testosterone LC/MS", or Hormone panel 3:

Hormone panel 3FINALLY, if you need any help, let us know!

Refill Request and Information

Information about Refills

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