HRT/TRT Prescription Submission
Patient Full Name
*
Phone
*
Email
*
Date of birth
*
HRT/TRT Prescription for Pharmacy
*
Provider Digital Signature
*
Submit Rx to Pharmacy
By checking this box and submitting your information, you provide your explicit consent to receive text messages and phone calls from Vitalis Wellness. 1. Agreement to Communications: You understand and agree that these communications may include automated, pre-recorded, or artificial/AI voice technology. 2. Marketing Consent: You also agree to receive marketing and promotional communications about our products, services, and offers. 3. Opt-Out Information: Message and data rates may apply. Consent is not required as a condition of purchase. You can opt out at any time: To stop text messages, reply STOP to any message. To stop phone calls, please notify the agent or press the appropriate key during an automated call, or call us directly at 719-453-0088.
