NEW Rx Submit .:. Manual Entry
PLEASE NOTE: We do not fill prescriptions for any provider, written by that provider. It might be legal, but it is not something I do. WE ALSO DO NOT COMPOUND GLP1 OR BIOLOGICS. Ever.
Provider Name:
*
Provider First Name
Provider Last Name
Provider Title:
*
MD, DO, FNP, RN, APRN, DVM, DDS, etc.
Provider Email Address:
*
example@example.com
Provider License Number, NPI, or DEA #
*
DEA Number required for controlled substances.
Provider Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Provider Fax #:
*
FAX MACHINES ARE MY FAVORITE
Format: (000) 000-0000.
Person Submitting Name & Role in Practice:
*
First Name
Role
Provider Phone #:
*
Format: (000) 000-0000.
Patient Info
Patient Name: (Must be different than provider)
*
First Name
Last Name
Species:
Please Select
Human
Feline
Canine
Other
We do not judge. I used to identify as a cupcake before the war.
Gender:
*
Please Select
Male
Female
Non Binary
Other:
Patient Guardian / Parent / Owner Name:
Role:
Please Select
Mother
Father
Owner
Guardian
Other
Patient Date of Birth:
*
-
Month
-
Day
Year
WE PROMISE NOT TO SEND A BIRTHDAY CARD.
Patient Phone #:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email:
example@example.com
Patient Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Compounded Medication Info
Use of the word "CLICK" is offensive. Please use the volume of the dose intended. For example: Apply 0.5gm topically.
Compounded Medication Name:
*
Medication Strength:
*
Milligrams, Milligrams per gram, etc.
Medication Form:
*
Please Select
Capsule
Cream
Liquid
Sublingual
Suppository
Injection
Eyedrop
Other
Medication Instructions:
*
Please use the volume of the dose intended. For example: Apply 0.5gm topically.
Days Supply:
*
Refills Permitted:
*
As per FDA's GFI 256, it is required to note the medical rationale for prescribing a compounded medication over a commercially available medication
*
1. Patient is allergic to a specific ingredient in the FDA approved product
2. Specific ingredient in FDA approved product is toxic to this species
3. Patient would require too many pills/tablets of FDA approved product
4. Patient needs a dose that would require a fraction of an approved tablet and tablet is not scored to accomplish this fractionated dose
5. Patient cannot safely be pilled with the FDA approved capsule
6. Commercial product is not available, in short supply, or on backorder
7. Commercial product is not available in requested dosage form
Other
If #1 or #2 or other is checked, please list ingredient/reasoning here:
Signature:
Any special notes for this prescription?
For example: Please contact the doctor's office OR the patient for payment, make the suppository flavored, only dispense in pairs of 3, etc.
Please verify that you are human:
*
Continue
We have not received this prescription until you click through, confirm your signature and land on the THANK YOU screen.
Click continue, click CONFIRM SIGNATURE, and everybody wins. If you don't click CONFIRM SIGNATURE, everyone loses. From what I understand, an angel loses their wings too.
Should be Empty: