Wyoming Wellness Center

Available Forms

Copy of Medical and Psychosocial Intake Form Medical and Psychosocial Intake Form Prescription Refill Request

Prescription Refill Request

Patient Name *

Must include first and last

Patient DOB *

Patient Phone Number *

Pharmacy - Please specify which location *

Medication Refill Request *

Please allow 5 days for requests on all current medications. **AN APPOINTMENT MAY BE REQUIRED BEFORE REFILL-SEE BELOW** For Opioids & Ketamine - Every Month (Updox or phone) Check-Ins & Every 3 Month Appointments (Telehealth or In-Person). For LDN or Other medications - Every 6 month (Updox or phone) Check-Ins, Every 12 month Appointments (Telehealth or In-Person).

* Required field