First Name:

Last Name:

Date of birth:

Phone Number: (XXX-XXX-XXXX)

(Please use the number we have on file for you)

Email: (Example: name@emailbox.com)

Account Number: (optional)

Please estimate how many days of medication you have remaining and select from below:

0 (no medication left) 1 day 2 days 3 days 4 days 5 days 6 days 7 days 8 days 9 days 10 days 11 days 12 days 13 days 14 days 15 days 16 days 17 days 18 days 19 days 20 days 21 days 22 days 23 days 24 days 25 or more days

To update your account information, please click here: https://www.usmed.com/current-patients/change/

I acknowledge receiving the medications listed on the packing slip. Please renew my prescription as needed. I am using the medications as prescribed. I require and request that you please send my breathing medications upon receipt of this form or one month after my last shipment, whichever is later, since I am or will be nearly exhausted of supplies and medications.
 

Sorry, we couldn't process your request at this time, please call us at 1-877-840-8218 to place your request.