$50 Fast Refill Form

I agree to use a Maryland pharmacy.*

I understand that this is a request for 2 weeks of medication.*

I attest that I have been prescribed this medication in the past.*

I am out of my medication and unable to get a timely appointment with my original prescriber.*

 I require this medication to avoid opiate addiction relapse.*

 I agree that this medication is for my own personal use*

 I will not sell this medication or give it to another person.*

 I agree to keep this medication in a safe place away from children, as it is LETHAL if taken by a child/infant/toddler.*

 I will not take this medication with a benzodiazepine (like alprazolam, lorazepam or diazepam).*

I agree to do a telehealth visit or in office with Nurse Practitioner Bonnie Velez within the next 60 days.*

I agree to do a virtual visit or in office visit for drug toxicity testing mouth swab within the next 60 days.*