AquaDrip Wellness Medication Refill Consultation

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Phone Number* This field is required.
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ALLERGIES/REACTIONS:* This field is required.Please list any allergies to medications and reactions. If none write NONE.
Foods, medications or dust
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DISEASE/CONDITION (Leave blank if no past medical history):* This field is required.
Current
Past
Date Diagnosed, Experienced Symptoms, Treatment
Asthma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Cancer (Type)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Diabetes (Type)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
High Blood Pressure (Hypertension)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Heart Disease
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Renal/Kidney Disease
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Migraine Headaches
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
High Cholesterol
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Other:
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
None
Row 9, Column 0
Row 9, Column 1
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Asthma
Cancer (Type)
Diabetes (Type)
High Blood Pressure (Hypertension)
Heart Disease
Renal/Kidney Disease
Migraine Headaches
High Cholesterol
Other:
None
Current
Row 0, Column 0
Past
Row 0, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 0, Column 2
Current
Row 1, Column 0
Past
Row 1, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 1, Column 2
Current
Row 2, Column 0
Past
Row 2, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 2, Column 2
Current
Row 3, Column 0
Past
Row 3, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 3, Column 2
Current
Row 4, Column 0
Past
Row 4, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 4, Column 2
Current
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Past
Row 5, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 5, Column 2
Current
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Past
Row 6, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 6, Column 2
Current
Row 7, Column 0
Past
Row 7, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 7, Column 2
Current
Row 8, Column 0
Past
Row 8, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 8, Column 2
Current
Row 9, Column 0
Past
Row 9, Column 1
Date Diagnosed, Experienced Symptoms, Treatment
Row 9, Column 2
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SURGERIES (Leave blank if no past surgical history):
Type(Specify Left or Right)
Date of Surgery
Location/Facility
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Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
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Row 4, Column 0
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Type(Specify Left or Right)
Row 0, Column 0
Date of Surgery
Row 0, Column 1
Location/Facility
Row 0, Column 2
Type(Specify Left or Right)
Row 1, Column 0
Date of Surgery
Row 1, Column 1
Location/Facility
Row 1, Column 2
Type(Specify Left or Right)
Row 2, Column 0
Date of Surgery
Row 2, Column 1
Location/Facility
Row 2, Column 2
Type(Specify Left or Right)
Row 3, Column 0
Date of Surgery
Row 3, Column 1
Location/Facility
Row 3, Column 2
Type(Specify Left or Right)
Row 4, Column 0
Date of Surgery
Row 4, Column 1
Location/Facility
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MEDICATIONS (List current medications):* This field is required.
Medications
Dose(how many milligram)
Times Per Day
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Row 0, Column 1
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Row 1, Column 0
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Row 3, Column 0
Row 3, Column 1
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Row 4, Column 1
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Medications
Row 0, Column 0
Dose(how many milligram)
Row 0, Column 1
Times Per Day
Row 0, Column 2
Medications
Row 1, Column 0
Dose(how many milligram)
Row 1, Column 1
Times Per Day
Row 1, Column 2
Medications
Row 2, Column 0
Dose(how many milligram)
Row 2, Column 1
Times Per Day
Row 2, Column 2
Medications
Row 3, Column 0
Dose(how many milligram)
Row 3, Column 1
Times Per Day
Row 3, Column 2
Medications
Row 4, Column 0
Dose(how many milligram)
Row 4, Column 1
Times Per Day
Row 4, Column 2
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Medication Refill Consultation

These are the medications that are not eligible for refill at Aqua Drip Wellness:

Medications prescribed outside of the country
Controlled substances such as narcotics and sedatives
Medications for chronic pain, muscle relaxation, and nerve pain such as gabapentin and pregabalin
Promethazine, a medication used to treat allergies and nausea
Medications for ADHD and amphetamines
Medications for weight loss including phentermine, Saxenda, Victoza, Ozempic, Wegovy, Mounjaro, and Rybelsus
Hormone replacement therapy
Medications that modulate or suppress the immune system
Injectable medications such as Trulicity and dulaglutide (insulin and epinephrine are allowed)
Medications for mental health conditions such as antipsychotics and mood stabilizers
Clomid, a medication used for infertility treatment, and Coumadin/Warfarin, a medication to prevent blood clots
Compounded medications
Any newly prescribed medication or dosage changes
Antibiotics (oral or topical), antivirals such as Valacyclovir/Acyclovir, and antifungals
Refills of Prednisone are only available for stable chronic conditions with a 30-day supply limit and no treatment for flare-ups.
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What medication do you need refilled?* This field is required.
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What is the reason you take the medication?* This field is required.
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How many days refills do you want?* This field is required.
30 days
60 days
90 days
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When is your next follow up with your primary healthcare provider (Prescriber)* This field is required.
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Enter any additional symptoms/information
*If you are having any life threatening/serious symptoms or a serious medical condition this is not an appropriate evaluation and we will not Rx any treatment.
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Where should we send your Rx? (Enter pharmacy name, address, city, zip code and phone number)* This field is required.
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Terms and Conditions* This field is required.
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Medication Refill Consultation
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ORDER SUMMARY
Total costUSD
Medication Refill ConsultationIncludes consultation and medication refill to pharmacy of your choice, 30, 60 or 90 day refill. Does not include price of medication.
$34.99Edit
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