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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

Healthcare Provider

Provider Name*

Prefix First Last

Enter Provider First, Last Name

Phone*

Office/Practice Name (if applicable)

Email*

Patient Information

Patient Name*

First Last

Preferred Phone Number*

Patient Email

Recommended Supply

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)

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Contact

1212 Collier Road NW, Atlanta, Georgia 30318

877.421.7160

HCP@solvwellness.com

1212 Collier Road NW | Atlanta, Georgia 30318

1.877.421.7160

HCP@solvwellness.com

*GennaMD is the most potent cranberry PAC supplement per milligram as a result of its advanced extraction process, resulting in a small capsule with no unnecessary fillers.

*GennaMD is backed by three clinical studies. 21 studies support its 100% soluble cranberry juice-based PAC formula.

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

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