Wellness & Performance Refill

TPG Request Form — Refill / Bloodwork / Insurance Invoice

Use this form to request a prescription renewal, updated bloodwork, or an insurance-ready invoice. Your submission will be securely reviewed by our health practitioners and coordinators, and we will contact you with the appropriate next steps. All prescription-related requests require clinical approval and may be subject to standard administration fees

Name

First Last

Date of Birth

Phone

What are you requesting?(Required)

Prescription Refill

Requisition & Follow-Up Appointment

Detailed Insurance Invoice Request

Prescription Refill Request

Use this section if you are requesting a prescription refill. All refill requests must be clinically reviewed to ensure they meet safety and eligibility requirements. A refill can only be issued if you have had a follow-up appointment within the last 3 months, or if recent bloodwork (within 3 months) is on file. If these requirements are not met, a follow-up appointment will be required before the refill can be processed. Medication costs are billed separately based on the treatment requested.

Medication Requested(Required)

Refills require a health practitioner visit within 3 months OR bloodwork within 3 months. If neither applies, a follow-up appointment is required.

Current Dose (optional)

Notes / Reason for Refill (Optional)

Acknowledgement (Required)(Required)

I understand that all prescription refills require clinical approval. I acknowledge that the medication cost will be invoiced separately based on the treatment requested, and that an invoice and Interac payment request will be sent to me once the refill is approved.

Bloodwork Requisition Request & Follow-Up Appointment

Use this section if you are requesting a new bloodwork requisition. All requests are reviewed by a health practitioner to ensure the appropriate tests are ordered. A $75 administration fee applies, which includes the follow-up appointment to review your results. Once your results are received by our clinic, we will contact you by email to coordinate the follow-up appointment.

Please specify any additional tests you would like included

Notes (Optional)

Acknowledgement (Required)(Required)

I understand that a $75 administration fee applies for a bloodwork requisition request, which includes the follow-up appointment to review my results. I acknowledge that the clinic will contact me once my results are received to coordinate next steps.

Insurance Invoice Request

Use this section if you require a detailed invoice to submit to your insurance provider. Please ensure the information you provide is accurate, and allow up to 2 business days for our accounting team to prepare and send your invoice.

Please specify which prescription you require an insurance invoice for.

Include the prescription name and the date it was purchased so we can locate the correct invoice.

Notes (Optional)

Add anything else that may be relevant to your request.

TPG Request Form — Refill / Bloodwork / Insurance Invoice

Prescription Refill Request

Bloodwork Requisition Request & Follow-Up Appointment

Insurance Invoice Request

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