Top Health Center

Name *

Date of Birth *

Email *

Phone Number *

Address *

Sex *
Male Female Other

1 - No Refills for Opioid, Sedatives, Stimulants, Psychotropics and Insomnia control medications

Provide diagnosed conditions to which you are taking the prescriptions for.

2 - Please type your prescription exactly as it appears on your bottle label.

3 - Place Picture of label with circled component of each question with definitions.

4 - What is the reason for the need of refill?*

5 - When was the last time you filled this medication, and how many pills were you given?

6 - Who originally prescribed the medication you want refilled, and when are scheduled to see them again?

7 - What is your Age?

8 - What is your Gender?*

Male
Female
Transgender

9 - Please list ALL your prior medical history?*

10 - Please list ALL of your medications (prescription and over the counter) including the one you want refilled and next to it write for how long have you been on those medications?*

11 - Do you have any Medication Allergies?

12 - Have you experienced any side effects with any medications in the past?

13 - Do you have any symptoms at this time?

14 - Please enter preferred pharmacy information.*

Include a complete information where you would like to pick up your medication.

Upload Past Medical Records *

Drop files here to upload

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.