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

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

Blind (required)
 Yes No

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

Patient Instructions (required)

____________________________________________________________________________________________________________________

Delivery Method (required)
 Pickup Mail

Notes to Medicinary

Payment Method (required)