Prescription Request

Please allow at least five days for the prescription request to be processed.

NOTE: Please submit all prescription requests for the same individual in a single form. We highly recommend that you review the instructions for submitting a prescription request (click here )

Prescription Request

1. Date of request *

2a. Patient First Name *

2b. Patient Last Name *

3. Date of birth *

4. Agency name (if applicable)

5a. Office/Home Phone number *

5b. Mobile Phone Number

6a. Primary Email *

6b. Secondary Email

7a. Name of person making the request *

7b. Relationship to Patient *

(Example: caregiver, parent, direct service provider (DSP), nurse, etc.)

8. Any other information that you would like us to know?

9. Prescription Request *

Primary Care

Psychiatry

Neurology

Cardiology

Endocrinology

Podiatry

Ophthalmology

Urology

Dermatology

Nutrition

Physiatry

OB/GYN

9a. Name of primary care provider

9b. Name of psychiatrist

Note: The request must have a minimum of a 7-day supply in order to be processed

9c. Name of neurologist

9d. Name of podiatrist

If you are human, leave this field blank.

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