Order New Rx

Order New Rx

Thank you for choosing Valor Compounding Pharmacy! This HIPAA secure form can be used for one of the following 3 reasons: 1) You are an existing Valor patient and have a new prescription from your doctor that you would like us to fill; 2) You are a new patient to Valor and would like us to contact your doctor about a new prescription; or 3) You are a new or existing Valor patient and would like a doctor referral for a specific area of medicine that you are seeking.
Please note: We do not make peptides, IV nutrients or vitamins, growth hormones, semaglutide, tirzepatide, or other weight loss compounds.
* Required Fields
Are you a current Valor patient?
Are you a current Valor patient?
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has your home address changed in the last 3 months?
Patient Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your shipping address the same as your home address?
Patient Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
I would like to receive emails containing marketing, education, promotions, and/or compound information from Valor Compounding Pharmacy.
Are you a First Responder?
Valor is happy to provide a 20% discount for First Responders.
Please upload your valid employer ID.

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When is the best time to reach you?
State to Ship To
We can only ship to these states that we are currently licensed in at this time.
Doctor Information

Please indicate your prescriber's information and we will contact him/her to request your prescription.
Do You Have a Doctor?
Do You Need a Doctor?
Doctor's Name
Doctor's Phone Number
Prescription Information

You may upload a New prescription here, or indicate information about the prescription you are seeking and we may be able to follow-up with your doctor on your behalf.
Do you have a valid prescription written by your doctor that you would like to upload?
Upload a copy of your written prescription from your doctor.

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Requested Medication

Please tell us the compounding medication you are requesting or provide a brief description of your medical condition being treated.
Compound Information
What was the price of your previous compound medication?
Any additional information you would like to provide?
How did you hear about us?

Other
Would you like us to provide an universal claim form with the package for possible reimbursement from your insurance company?
**You will need to contact your insurance carrier to ask about your benefit coverage of compound medications. Valor does not guarantee reimbursement by your insurance plan.
Thank you for completing the new prescription form. You may electronically submit this request to Valor Compounding Pharmacy by clicking "Submit" below.

A Pharmacist will contact you within 1 business day.
Please verify that you are human
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Order New Rx

Doctor Information

Prescription Information