Prescription Refills

Please include the PATIENT'S NAME below.
Please note that FedEx will not ship to a P.O. Box, the address needs to be a physical address. FedEx Next Day Air delivery does not include Saturday delivery. Refrigerated items require special shipping.

We accept American Express, Visa, MasterCard and Discover (please call 1-800-227-2627 to provide a credit card number or we will use the card from your last order).
** When we process this refill we will use the same credit card we used on your previous order. **
Please do NOT include credit card information when completing this Secure Online Refill Form.

* First Name:
* Last Name:
* Shipping Address:
Suite/Apartment No.:
* City:
* State:
* Zip Code:
Country:
* Your Email Address:
* Phone (In case we have any questions about your order):
Billing Address (if different from above):
Billing City:
Billing State:
Billing Zip:
1st RX#:
1st RX Quantity(Specify # of capsules, ml, troches, vials, grams, etc... for all RX#'s provided):
2nd RX#:
2nd RX Quantity:
3rd RX#:
3rd RX Quantity:
4th RX#:
4th RX Quantity:
5th RX#:
5th RX Quantity:
6th RX#:
6th RX Quantity:
7th RX#:
7th RX Quantity:
8th RX#:
8th RX Quantity:
9th RX#:
9th RX Quantity:
* Ship your order to you OR will you pick it up from us?
Call Wellness at 800-227-2627 to provide credit card number. Please do NOT include credit card information when completing this Secure Online Refill Form.
If for pickup, When would you like to pick up?
Special Instructions (list any known drug allergies here):

* Required Field