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

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
Name:       
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