Order Instructions
Please fax this form and prescription to (800) 736-9109:
Voice: (888) 701-4990

NOTE: Medication prices may vary based on prescription. You'll be contacted by the pharmacy prior to billing for additional information and the total price.
Patient Information
First Middle Initial Last
Billing Address:           
Street Suite or Apt. # City State ZIP Code
Shipping Address:           
(If different than above) Street Suite or Apt. # City State ZIP Code
Contact Information:   (            )  (            )  
Primary Phone Secondary Phone E-Mail Address
Date of Birth:            /          /   Please select your gender (check one):  Female    Male
Doctor Information
Doctor's Name:     
First Last
Contact Information:   (            )
Doctor's Phone
If your prescriber has allowed, a generic equivalent will be dispensed unless you check the following box:   I do not accept a generic equivalent
Payment Information
Credit Card Number:                /
(Visa, MasterCard, Discover, American Express) Expiration Date
Name (as it appears on card):       
First Middle Initital Last