Returning Patient Refill Request Order Form (10/16/2020)

If paying with CareCredit, please provide CareCredit Card Number, Name of Card Holder, and expiration date of your Driver License
Please contact us if you have questions. We only charge fees for the services provided and ONLY if you agree to the charges.
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I AM REQUESTING that you call me on my cell phone number DURING which time and date (write below) _______________. I AGREE THAT THERE IS A POTENTIAL DELAY OF 72 BUSINESS HOURS TO FOR A CALL-BACK. However, we typically send out plans and your instructions in the mail the same business day we speak to you on the phone. I agree to wait 3 business days for a phone call from Elevation Medical, then I will be provided with a tracking number of the mailed-out dietary guidance.