REQUEST A REFILL

Please allow 24-48 hours for processing of refill requests. You will be contacted when your prescription is ready for pick-up.

Name

First Name

Last Name

Contact Phone

(###)

###

####

Email Address

Herbal / Supplement Formula(s)

Enter the name of the herbal medicine or supplement formula you wish to refill:

Rx Number(s)

Enter the prescription number on your container or instruction sheet:

Message

Special requests, instructions, questions or comments about the current formula.

Refill requests are filled at the discretion of the practitioner. You may require a follow-up visit or consultation before a formula is refilled.