REFILL REQUEST

Thank you for requesting your refill(s) via our convenient and secure online form. Please fill out all the fields below. Once you submit, please be on the lookout for a call and/or text from a friendly Mandell's Patient Care Coordinator who will help you finalize your delivery. Your refill cannot ship until you finalize your delivery.

First Name *

Last Name *

Date of Birth *

Phone Number *

Which type of treatment cycle are you doing? *

By what date do you need to receive your refills? (Please note that refill requests received after 5pm EST (2pm PST) M-F and 2pm EST (11am PST) on Saturday will not be processed until the following business day.) * +

Have you had any changes to medical conditions or diagnosis since your last fill? *

Yes

No

Please detail your changes here. *

Have you made any changes to the medications or vitamins you currently take (if any), prescribed or over the counter? *

Yes

No

Please detail your changes here. *

Have there been any changes to your contact information and/or your emergency contact? *

Yes

No

Please detail your changes here. *

Have there been any changes to your allergies including: Food, Medications, Latex, or ANY other potential allergens, including nuts. If none, please indicate "None". *

Have there been any changes to your insurance coverage since your last fill with Mandell's? *

Please upload a copy of the Front & Back of your insurance card. *

Do you need trigger shot *(HCG, Ovidrel, Leuprolide PFS) at this time? *

Yes, Please refill my trigger shot

No, I have one at home / am filling it elsewhere / do not require a trigger

How many medications or items do you need to refill? *

REFILL #1 - Rx# and/or Product Name *

REFILL #1 Qty *

REFILL #1 Units *

REFILL #2 - Rx# and/or Product Name *

REFILL #2 Qty *

REFILL #2 Units *

REFILL #3 - Rx# and/or Product Name *

REFILL #3 Qty *

REFILL #3 Units *

REFILL #4 - Rx# and/or Product Name *

REFILL #4 Qty *

REFILL #4 Units *

REFILL #5 - Rx# and/or Product Name *

REFILL #5 Qty *

REFILL #5 Units *

REFILL #6 - Rx# and/or Product Name *

REFILL #6 Qty *

REFILL #6 Units *

REFILL #7 - Rx# and/or Product Name *

REFILL #7 Qty *

REFILL #7 Units *

REFILL #8 - Rx# and/or Product Name *

REFILL #8 Qty *

REFILL #8 Units *

REFILL #9 - Rx# and/or Product Name *

REFILL #9 Qty *

REFILL #9 Units *

REFILL #10 - Rx# and/or Product Name *

REFILL #10 Qty *

REFILL #10 Units *

REFILL #11 - Rx# and/or Product Name *

REFILL #11 Qty *

REFILL #11 Units *

REFILL #12 - Rx# and/or Product Name *

REFILL #12 Qty *

REFILL #12 Units *

I also need the following: *

Needles and/or Syringes

Sharps Container

Alcohol Swabs

None of the Above

I am participating with a financing program: *

Next steps

A Patient Care Coordinator will process your request as soon as possible. You will still need to make payment and schedule the shipment of your order. Please wait for a text and email from Mandell's which will include a link to finalize your order *

I have read "Next Steps" and am aware that I must follow the directions provided to finalize my order.

Comments

Please click submit to finalize your request.