Practitioner First and Last Name (required)

Practitioner Email (required)

Practitioner Phone Number (required)

____________________________________________________________________________________________________________________

Patient Name (required)

Patient Address (required)

Patient Phone Number (required)

____________________________________________________________________________________________________________________

Remedy (required)

Potency Value (required)

Potency Scale (required)
CMLM

Quantity (e.g. single dose, half dram, 2 dram, 1 oz, 4 oz, etc.)(required)

Blind (required)
YesNo

Refills (Refills are for current potency only, change of potency requires a new prescription)
0123456789101112

Patient Instructions (required)

____________________________________________________________________________________________________________________

Delivery Method (required)
PickupMail

Notes to Medicinary

Payment Method (required)
Bill my card on fileBill patient card on fileBill directly to patient