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 :
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SUPPLIES :

MEDICATION :
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MEDICATION :
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MEDICATION :
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MEDICATION :
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MEDICATION :
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MEDICATION :
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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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Insurance:

Defy Medical strives to provide both quality medical care along with affordable access to compounded medications, blood tests, and nutritional supplements. In order to accomplish this, Defy Medical does not accept any form of insurance. Many of the formulations we use in our therapies are not covered by insurance, and the cost of overall treatment is often less than when using insurance. On case by case basis, some insurance companies do reimburse for Hormone Replacement Therapy and Testosterone Replacement Therapy. It is each patient's responsibility to contact their own insurance company to confirm reimbursement. Defy Medical will not contact your insurance company nor will take any responsibility for any additional forms your insurance requires. Defy Medical provides claim assistance by completing the standard claim form (CMS-1500) for the patient to submit to their insurance company. If you would like to receive Claim Assistance, please contact patient services at info@defymedical.com.