Supplement Refill Request Form

NOTE: This Form is available only to current patients of the clinic.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Supplement Info

Please list all the supplements you wish to refill. Please be as specific as possible: a) Brand b) Supplement name c) Bottle size (ex: 120 capsules/bottle) d) Quantity

Payment Options

Please charge my credit card on file.

I would like to pay via e-transfer (drstefnd@gmail.com).

Other (please comment below).

Other Info

Supplement order pick up may be scheduled MONDAY - FRIDAY FROM 10AM - 5PM. Please let us know what day/time you would like to schedule your supplement order pick up. Please also include any other comments.

Patient Resources

Supplement Refill Request Form