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 via your secure patient portal. Please be sure that you have not blocked our patient portal SMS messaging number: 540-530-3040.

Please note: Patients who have not been seen in our office within the past 3 months, or who have outstanding follow-up visits or required lab work, will need to complete these continuity of care requirements prior to medication refills being approved.

Patient Information

First name

Middle Name

Last name

Phone

Date of birth

Month

Day

Year

Your Home Address to Mail Your Prescription if Indicated

Medication Information

Medication Name

Current Dose/Strength

Is this compounded?

Yes

Pharmacy Name for requested medication

If NOT a compounding pharmacy please provide your local pharmacy street address.

Pharmacy Phone Number (if known)

If you are requesting Testosterone, Please provide your driver's license number.

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.

If this is a compounded formulation please provide the last 4 digits of the credit card we have on file for billing.

By submitting this request, I confirm that the information provided is accurate and up to date. I also confirm authorization for House of Bloom to bill the card on file accordingly for fees and costs associated with this request per office policies.

Signature

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