Supplement Re-order Form

This form is for current patients only. Please complete it to request refills for supplements you need.

If we have the items and your card info, we will process the order for pickup.
If items are out of stock, we will contact you.
Without your card info, items will be kept for payment at our office.

Please note that supplements ordered without a follow-up visit in the last 6 months, or past the suggested duration on your treatment plan, are taken outside of medical direction. If you have questions about your treatment plan, please make a follow-up appointment. To view our office hours, click here.

Name

First Name

Last Name

Phone

(###)

###

####

Please select your ND

Supplement Refills

Please list ALL THE SUPPLEMENTS YOU WISH TO REFILL. Please be as specific as possible: a) Brand b) Product Name c) Bottle size (ex: 120 capsules per bottle) d) Quantity

Please acknowledge the following

YES you can charge my card on file and I will come to pick-up

I would like to pay with debit or cash, I will pay when I arrive for pick-up

Please let us know your preferred pickup date

Please note that we require 2 business days to get your order ready.

YYYY

Please let us know if you have any other comments

Supplement Re-order Form

Clinic info

Solutions