BDH Authorization Form

Complete to submit your secure prescription payment to
Brand Direct Health® Pharmacy

Your 90 day supply will ship within 1 business day of verifying a valid prescription from your Health Care Provider. If we experience any issues with processing your order, we will call you.

*Patient First Name:

*Patient Last Name:

*Patient Date of Birth:

*Shipping Address 1:

Shipping Address 2:

*Shipping City:

*Shipping State:

2 letter abbrev

*Shipping Zip Code:

5-digits

*Phone:

10-digits

Alt Phone:

*Email:

*90 Day Supply - Full Pay / 3-Pay:

Full Pay ($199.98 + tax where applicable)
3-Pay* ($66.66 + $6 fee + tax where applicable)

*Shipping method:

First-Class USPS ($6)
Fedex 2-Day ($25) No PO Box Addresses

Coupon Code:

*Card Number:

*Expiration Date:

transtype:

*Billing zip code:

5-digits

Add Vivara™ - 90 count

only $29.99 extra

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Order Summary:

3-Pay Rebill Amount:

100% money-back guarantee: Full refund if your needs are not met.

No return necessary. Limit to one refund per person, per product. Excludes shipping and convenience fees.

For potential additional savings, call 1-866-331-6440.

* 3-Pay is split into 3 monthly payments with a one-time $6 fee on the first payment