Medication Request Form

Medication Refill Request

Prescription requests are reviewed and processed Monday through Thursday until 5:00 p.m. and on Fridays until 2:00 p.m. Any requests submitted after 2:00 p.m. on Friday will be processed the following Monday.

 
Prescription refill are processed Monday through Friday only.  

For questions/concerns, please call or text:

(207) 613.6314


NOTE: This order form is ONLY for patients who have had a consult with one of our Medical Providers


The clinic will review your responses to ensure you are a current patient before submitting the order to the pharmacy.

Please click HERE to book a follow-up appointment.

 Please schedule an appointment if you have not been seen in the last six months.

Patient Information

Please select the date of birth of the patient.
Name
Name
Patient's first name
Patient's last name
Enter the primary contact number for the patient.
Enter the primary email address of the patient.
Please Answer this question if you have not done so before: What other concerns do you have?

Patient Medication Allergies & Reactions

Have there been changes to your allergies?

Patient Medication

Please select yes or no.
Enter changes here

Medical weight loss information:

If just starting, unsure, or are a HRT patient, put 0 or 4
We do our best to SHIP products within 24 Hours from when your order is placed.

Secure Payment

Please complete your payment below using our secure Square checkout.

Payment

Amount Entered by Customer

Pay Now

Your payment is processed securely by Square.
Do not enter any medical or health information on the checkout page.

HIPAA Compliant Logo

HIPAA Compliance Notice

We protect your privacy in accordance with the
HIPAA Privacy and Security Rules. Information submitted through this
form is encrypted in transit and handled only by
authorized clinical staff with a legitimate need to know.
We employ administrative, physical, and technical safeguards to help keep
your health information secure and confidential.

Learn more about how we protect your data
  • All form submissions are encrypted via SSL/TLS technology
  • Access to records is limited to verified medical staff
  • We adhere to the “minimum necessary” standard
  • Our team undergoes ongoing HIPAA and privacy training

Note: If your submission includes a payment, checkout is processed
securely by Square. Please do not include medical information
on the payment page. For assistance, call or text

(207) 613-6314
.