Patient Referral Form

New patients can get 25% off their first Solv Wellness order with your medical recommendation. 60-Day Happiness Guarantee!

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Clinician Name*

Prefix First Last

Enter Clinician First, Last Name

Phone*

Office/Practice Name (if applicable)

Email*

Patient Name*

Preferred Phone Number*

Patient Email

Select Recommended Supply*

GennaMD UTI supplement 30-DAY SUPPLY

GennaMD UTI supplement 60-DAY SUPPLY

GennaMD UTI supplement 90-DAY SUPPLY

GennaMD UTI supplement ONGOING USE – we will discuss with patient based on automatic refill program costs

Māge probiotic 30-DAY SUPPLY

Māge probiotic 90-DAY SUPPLY

Via vaginal moisturizer

Please recommend patient supply.

How did you hear about us?*

Healthcare Colleague or Professional Name (optional)

Patient Name (optional)

Other (optional)