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)
    YesNo

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

    Patient Instructions (required)

    ____________________________________________________________________________________________________________________

    Delivery Method (required)
    PickupMail

    Notes to Medicinary

    Payment Method (required)