Cycle Regulation Formula Refill

CYCLE REGULATION FORMULA REQUEST (ONLY FOR CURRENT PATIENTS OF YAO CLINIC)

In order to complete a request for a formula refill, we require the completion of this form. Please note the following:

If it has been a while since you have been seen 3-6 + months and you are asking for a refill for a formula specific to your cycle, we will need to book a consultation to ensure the formula is correct for the newest manifestation. We do consider it poor medical practice to refill formulas that are no longer appropriate and therefore we may end up phoning to book a personal consultation to update the formula. If you are unsure if the formula can be refilled, please phone us and we will be able to answer this personally 303-777-7891.
Please note that your formula will be processed in the order it was received and will be organized as quickly as possible.

Name*
First Last
Phone*
Best phone number, in case clinician has to phone you to discuss anything personally.
Email*
Number of Formulas I am on*
Please specify how many formulas you are on presently in regulating or adjusting your cycle.
- 1 Formula
- 2 Formulas (1st & 2nd Half of Cycle)
- 3 Formulas
- Other
Which Formulas are you requesting refills on?*
If you wrote OTHER above, please describe*
Symptom Update*
Please describe any changes or notes you wish to pass along regarding your symptoms or general updates. Do understand that if there are lots of changes that are difficult to adjust without an in person visit, we will likely phone you to schedule a consult.
Date of Last Formula/s
Please type in here the dates that your last formula/s were refilled. This date should be on the last bottle you received. Or perhaps you remember that it was refilled at your last consultation appointment, please reference this date. If multiple dates are necessary due to multiple formulas, please list them all.
Days left of current formula*
Days left of current formula (please list the one that has fewest days if you are requesting more than one)
Please enter a number greater than or equal to 0.
Refill Size*
Please describe refill size/amount if you selected OTHER*
Preferred Date to Pick Up or Receive By
Please provide us with your preferred date to pick up or receive by with any extenuating circumstances such as upcoming travel etc. that contribute to your need.
Credit Card On File?*
Do we have your credit card on file for formula refills? If we do not or you are unsure, please phone us at 303-777-7891 to let us know. NO REFILLS WILL BE PROCESSED WITHOUT A CREDIT CARD. All formulas are tailor made for the individual and once it is created, it can not be returned to our inventory.
Any other changes to make to formula
Please describe here any changes you were wishing to make to this formula. It is not guaranteed that we can make these changes without an Internal Medicine Consult, but if you are wanting to communicate any changes, this is the place to do it.
How do you want to receive your formula?*
If we are shipping, please provide SHIP TO Address below*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Comments
This field is for validation purposes and should be left unchanged.

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Cycle Regulation Formula Refill

CYCLE REGULATION FORMULA REQUEST (ONLY FOR CURRENT PATIENTS OF YAO CLINIC)

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