Practitioner First and Last Name--Let Us Know if Your Phone Number or Email Has Changed (required)

Practitioner Email (required)

Practitioner Telephone

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Patient Name (required)

Patient Address(required)

Patient Phone Number (required)

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Formula(required)

Format (required)

Quantity (e.g. bottle, dose, gram)(required)

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

Patient Instructions (required)

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Delivery Method (required)
 Pickup Mail

Notes to Medicinary

Payment Method (required)