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 *

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. *

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 refills do you need? *

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

Next steps
A Patient Care Coordinator will process your order as soon as possible but we will need to speak to you in order to schedule your shipment. Please watch for a text message from Mandell's, which will include directions on how to finalize your order. *

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

Comments

Please click submit to finalize your request.