Thank you! Your Refill Request will be confirmed shortly.
There was an error submitting the form.
REFILL REQUEST FOR ESTABLISHED PATIENTS ONLY
PATIENT NAME
ITEM AND QUANTITY
ITEM AND QUANTITY
ITEM AND QUANTITY
ITEM AND QUANTITY
ITEM AND QUANTITY
ITEM AND QUANTITY
WHEN YOU PREFER YOUR REFILLS TO BE READY FOR PICKUP?
WHAT TIME WOULD YOU LIKE TO PICK UP YOUR REFILL?
Hours
01
02
03
04
05
06
07
08
09
10
11
12
AM
PM
ADDITIONAL INFORMATION
Do not include credit card information in your refill request.
Delivery Option
Pickup at the Clinic
Send by USPS
Patient Email
Patient Telephone
Email:
info@oregoncitywholistichealth.com
or
drgshahbaz@yahoo.com
Location:
216 6th Street
Oregon City, OR 97045-1803
Telephone: 503-657-4043
Fax: 503-657-8610
Website
provided by
Vistaprint
