REFILL REQUEST FORM

Important Refill Policy

Refills are reviewed by our clinical team and are not guaranteed without appropriate follow-up and/or lab monitoring.

Some medications require updated labs or a follow-up visit before refill approval.

Once your refill has been processed and sent to the pharmacy, House of Bloom is not responsible for pharmacy processing times, shipping delays, backorders, or lost shipments.

For questions regarding shipping, tracking, inventory, or delivery issues, please contact the pharmacy directly.

Medication Refill Request Form

To ensure timely processing of your refill request, please complete all fields below.

Please allow up to 2 business days for requests to be reviewed and processed by our clinical team.

If additional information is needed — or if a follow-up appointment is required prior to refill approval — our office will contact you at the phone number provided on this form.

Patient Information

First name

Middle Name

Last name

Phone

Date of birth

Month

Day

Year

Medication Information

Medication Name

Current Dose/Strength

Pharmacy Name

Compound

Yes

Pharmacy Location (City/State)

Pharmacy Phone Number (if known)

Date of Last Appointment with House of Bloom

Have you experienced any side effects or changes since your last visit?

Yes

Have there been any changes to your medical history or medications?

Yes

If you answered yes to any of the questions above, please supply additional information.

By submitting this request, I confirm that the information provided is accurate and up to date.

Signature

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Date