NEW Rx Submit :|: Manual Entry

NEW Rx Submit :|: Manual Entry

PLEASE NOTE: WE DO NOT FILL PRESCRIPTIONS WRITTEN BY THE PROVIDER, FOR THE PROVIDER. It might be legal, but it is not something we do. WE ALSO DO NOT COMPOUND GLP1 OR BIOLOGICS, so any RX received for those items will be shredded.
Provider Name*

First NameLast Name
Provider DEA or NPI#*
Provider Address*

Street Address

Street Address Line 2

CityState

Zip Code
Person Submitting Name & Role in Practice*

First NameRole
Provider Phone #*
Provider Fax #*
Provider Email Address*
example@example.com
Patient Info
Patient Name*

First NameLast Name
Species
Gender*
Other
Patient Guardian / Parent / Owner Name
Role
Patient Date of Birth*

MonthDayYear
Date
Patient Phone #*
Please enter a valid phone number.
Patient Email
example@example.com
Patient Address

Street Address

Street Address Line 2

CityState

Zip Code
Medication Info
Medication Name*
Medication Strength*
Medication Form*
Medication Instructions (NOT USING THE WORD CLICK)*
IF YOU ARE PRESCRIBING A TOPICAL, do NOT use the word CLICKS in the instructions. Use "0.25gm", "0.5gm", or "1gm".
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 product2. Specific ingredient in FDA approved product is toxic to this species3. Patient would require too many pills/tablets of FDA approved product4. Patient needs a dose that would require a fraction of an approved tablet and tablet is not scored to accomplish this fractionated dose5. Patient cannot safely be pilled with the FDA approved capsule6. Commercial product is not available, in short supply, or on backorder7. Commercial product is not available in requested dosage formOther
If #1 or #2 or other is checked, please list ingredient/reasoning here
Signature

Powered by Jotform SignClear
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*
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.
Should be Empty:

NEW Rx Submit :|: Manual Entry

Patient Info

Medication Info

We have not received this prescription until you click through, confirm your signature and land on the THANK YOU screen.