Refill PT Invoice Request

First Name *

Last Name *

What is the best email to send an invoice? *

What verified address are we shipping this order to? *

Is the patient's NP Televisit date within 12 months? *

Yes

Is the patient's blood work date within 12 months? *

Yes

When was the last invoice paid? +

How many Items will be added to this invoice? *

Review

Please use the following template to list medications & Syringes:
(ex. of templates below) (please list the directions tailored to PT program)*

**Testosterone Cream Click 200mg
QTY 3
Directions - 2 pumps am / 2 pumps pm

**Testosterone Cypionate 200mg

QTY: 1 pack of 2 - 5ml vials
Directions: inject .3ml 2x per week

**Anastrozole .5mg
QTY: 10
Directions: Take 1 Tablet by mouth every Friday

**Semaglutide 2ml Vial

QTY: 1

Directions: Inject .12ml subcutaneously 1x per week

What items would you like to be added to this invoice?

Note: States you should not submit tirzepatide orders without a reshipping fee are:

Alabama
California
Idaho
Kentucky
Mississippi

All "Wells 16.6mg - 4.5ml" orders from those states, will be defaulted to 2 - 10mg vials + a re-shipping fee.

Which type of Shipping should be added to this invoice? *

Shipping Fee - $35.00

Refrigeration Shipping Pack - $50.00

RX Lab/ROS Update - $399

Current PT Lab Panel Request - $299

+ Reshipping Fee - $100 (cant ship to state)

RX Televisit (ROS) Only - $100

Please note all orders come with a $50.00 Processing Fee, except labs*

Additional Notes:

Renew Life Wellness Coordinator Name: *