Vital Health Institute: Prescription Refill Request Form

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Prescription Refill Request

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Please fill out the form below to request a refill on your prescription. Your request will be processed within 2 working days.

IF THIS IS AN EMERGENCY REFILL REQUEST, PLEASE CALL THE OFFICE AT (408) 358-2511.

This is a secure web page. This form uses an advanced security configuration system. The information you submit will be encrypted for your protection.

* = Required field

First Name*

Last Name*

Email Address*

Retype Email Address*

Call Back Number*
- -

Medication*

Strength*

Directions*

Quantity Requested*

Pharmacy Name*

Pharmacy Phone Number*
- -

Preferred method of receiving prescription*

Complete below if this is request for Narcotic Refill

If Narcotic - Average
Number Used per Day

If Narcotic - How many pills
do you have left now?

Shipping your prescription via courier (e.g., FedEx or UPS) requires the following information:

Name on Card *

Credit Card Type*

Billing Zip Code*

Credit Card Number (no spaces or hyphens)*

Credit Card Expiration Date*
/

Security Code*

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The content contained in this web site is for informational use only and is not intended as medical advice. You should always seek the advice and care of your local physician. Information on this web site is also subject to change without notice and may include technical inaccuracies or typographical errors.

Vital Health Institute is an international treatment center specializing in endometriosis, chronic pelvic pain, and minimally invasive laparoscopic surgery.
Women travel from throughout the U.S., Canada and countries worldwide for treatment by Dr. Andrew Cook and his dedicated, professional staff.