AppleGate Recovery Brentwood TN - Medication Request

Medication Request
Form Title
ABOUT YOU
Your Name*

FirstLast
Mobile Phone*
You will receive an SMS text at this number AFTER your refill has been sent to your pharmacy
Email*
Date of Birth*

MonthDayYear
Date
MEDICATIONS

List the name of each medication to be refilled. Your physician will verify medication names and quantities before they are processed.
Suboxone Medication
Do you have other medications that require a refill?
Other Medication 1
The name of any other medication to be refilled
Other Medication 2
The name of any other medication to be refilled
Other Medication 3
The name of any other medication to be refilled
Other Medication 4
The name of any other medication to be refilled
PHARMACY
Pharmacy Name*
Other Pharmacy Name
Pharmacy Phone*
Please include the area code.
PAYMENT
Select your payment amount*
prevnext( X )
1 Week
$100



2 Weeks
$200



4 Weeks
$350
AGREE TO TERMS
By clicking the button below I am agreeing to all terms and conditions listed above and also those items listed in my Patient Recovery Contract. I am authorizing Applegate Recovery to charge my card for the selected amount.

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Medication Request