Order Request - On the Bright Side
IF YOU ARE A NEW PATIENT, PLEASE COMPLETE THE NEW PATIENT PAPERWORK INSTEAD OF THIS FORM.
Returning patients: After you fill out this order request, we will contact you to go over details and availability before the order is completed and to take preferred payment option, also pending pharmacy readiness. More questions? Please text the office at 480.600.2403. Please allow 48 hours from time of form submission for us to be in touch.
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Email *
IF YOU ARE A NEW PATIENT, PLEASE COMPLETE THE NEW PATIENT PAPERWORK INSTEAD OF THIS FORM.
Are you a new or existing customer? *
What is the item you would like to order? *
Please choose below.
Required
Quantity needed (how many shots)? Dosing (units on syringe)? “Same as last time” will delay your order. *
Your name *
Phone number *
Address (street, city, state, zip) *
Email address (shipping confirmation will be sent here) *
Shipping Options *
Preferred method of payment? *
How did you hear about us? *
Refills:  All refills will require a 2 week notification.  I understand, I may need to request refills ahead of time to avoid delays in refills in case of backorders or shipping issues . Complete request for refill on website, www.onthebrightsideAZ.com when you have 2 shots remaining, Office Line: 480-600-2403 *
CLOSED NOTICE: We will be closed July 14th and 15th. All orders will be processed on July 16th. Thanks :) *
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