This prescription refill form is only for patients of Defy Medical only. If you are not currently a patient, please contact our clinic to schedule a free consultation to learn how to receive treatment.

To request your refill, please complete this form and submit. Your request will be processed within one business day. Contact Defy Medical if you have any questions or need assistance with your medications.

Fields with a * are required.
PERSONAL INFORMATION
FULL NAME : *
DATE OF BIRTH : *
EMAIL ADDRESS : *
CONTACT PHONE NUMBER : *
BILLLING INFORMATION
BILLING ADDRESS : *
BILLING ADDRESS :
BILLING CITY : *
BILLING STATE : *
BILLING ZIP : *
MEDICATIONS
MEDICATION : *
QUANTITY : *
SUPPLIES :

MEDICATION :
QUANTITY :
SUPPLIES :

MEDICATION :
QUANTITY :
SUPPLIES :

MEDICATION :
QUANTITY :
SUPPLIES :

MEDICATION :
QUANTITY :
SUPPLIES :

MEDICATION :
QUANTITY :
SUPPLIES :

MEDICATION :
QUANTITY :
SUPPLIES :

MEDICATION :
QUANTITY :
SUPPLIES :
SHIPPING INFORMATION  
SHIPPING ADDRESS : *
SHIPPING ADDRESS :
SHIPPING CITY : *
SHIPPING STATE : *
SHIPPING ZIP : *
SHIPPING METHOD : *
SIGNATURE REQUIRED AT DELIVERY : YES NO
 
PLEASE VERIFY YOUR ORDER BEFORE SUBMITTING
   
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