Medication Refill Request

Need a refill? Fill out the form below and our team will review your request. Please allow up to 2 business days for processing. Some refills may require a follow-up visit or updated labs before we can approve them. For urgent medical concerns, call 828-528-6290. For emergencies, call 911.

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address

Street Address *

City *

State

Country

Enter your country

Postal Code *

Medication Name *

Strength *

Dose *

Frequency *

Other Frequency

Ship this medication to *

My primary address above

A different address

Alternate Shipping Address

Would you like to request another medication? *

Yes

Medication Name #2

Strength For Medication #2

Dose For Medication #2

Frequency For Medication #2

Other Frequency Medication 2

Ship this medication #2 to

My primary address above

A different address

Alternate Shipping Address For Medication #2

Would you like to request a third medication?

Yes

Medication Name #3

Strength For Medication #3

Dose For Medication #3

Frequency For Medication #3

Other Frequency Medication 3

Ship this medication #3

My primary address above

A different address

Alternate Shipping Address For Medication #3

Would you like to request a fourth medication?

Yes

Medication Name #4

Strength For Medication #4

Dose For Medication #4

Frequency For Medication #4

Other Frequency Medication 4

Ship this medication #4

My primary address above

A different address

Alternate Shipping Address For Medication #4

Since your last refill, have you had any new symptoms, side effects, medication changes, or health changes? *

Yes

Please describe

Anything else we should know?

Would you like to use the card we have on file? *

Yes

No, I need to update my card

Last 4 digits of the card you’d like us to charge *

I authorize High Country Wellness to charge my card on file ending in the digits above for this refill order. *

Yes

Please call us at 828-528-6290 to update your card. For your security, do not enter your full card number on this form.

I confirm the information above is accurate. I understand refill requests are reviewed by a provider and are not guaranteed. A follow-up visit or updated labs may be required before approval. This form is not for urgent or emergency needs.

Signature *

Clear

Need to submit a Supplement Refill Request? Please fill out this form here.