Supplement Refill Request

Running low on your supplements? Let us know what you need below. We’ll have your order ready for pickup or shipped to your door. Please allow up to 2 business days for processing. Questions? Call us at 828-528-6290.

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.