Patient Refill Request After you fill out this order request, we will reach out should we need clarification and send you the invoice and tracking number. If you would like information on pricing and other inquiries please email us at info@redoxmedicalgroup.com. Email(Required) Name(Required) First Last Patient Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are we shipping to the address on file?(Required) Yes - Awesome No Please note: shipments will be between 2-4 business days unless it’s a holiday which will add another couple business daysEnter your address if different from the one on file.WHAT PEPTIDES DO YOU NEED REFILLED? Please include QTY.(Required)Example: BPC-157 Injection - 1 vial, SeLANK Nasal Spray - 2 bottles | Please put N/A if not applicable.WHAT MEDICATION OR SUPPLEMENTS DO YOU NEED REFILLED? Please include QTY.(Required)Example: Prodrome Neuro Caps - 1 bottle, L-Leucine+Na - 2 bottles | Please put N/A if not applicable.Need Syringes?(Required) Yes No Need Alcohol Pads?(Required) Yes No Additional Notes/Requests/Questions(Required)Please put N/A if not applicable.
