formula refill 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 you have more than one formula that you want refilled, you need to complete this form for EACH formula.
  • If it has been a while since you have been seen 3-6 + months and you are asking for a refill for a formula for an illness/condition that was of assistance, we will need to book a consult to ensure the formula is correct for the newest manifestation of illness.  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 consult 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 take a minimum of 2 days and  generally a maximum of 5 days.
Name *
Name
Phone *
Phone
Best phone number, in case clinician has to phone you to discuss anything personally.
Please describe the formula as to what it was being used for OR the name that it has on the current label.
Date of last formula
Date of last formula
If unsure of date of last formula, please describe the approximate date
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.
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.
Please provide our clinicians with an update on your symptoms and how this formula has been working. If you have nothing to report, please say this as well.
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.
If there is something else you wish to communicate that does not fit into the above format, please let us know here.
If we are shipping, please provide SHIP TO Address below
If we are shipping, please provide SHIP TO Address below