NEW Rx Submit :: Manual Entry

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 NameProvider 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

CityState

Zip Code
Provider Fax #:
FAX MACHINES ARE MY FAVORITEFormat: (000) 000-0000.
Person Submitting Name & Role in Practice:

First NameRole
Provider Phone #:
Format: (000) 000-0000.
Patient Info
Patient Name: (Must be different than provider)

First NameLast Name
Species:
We do not judge. I used to identify as a cupcake before the war.
Gender:
Other:
Patient Guardian / Parent / Owner Name:
Role:
Patient Date of Birth:

MonthDayYear
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

CityState

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:
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
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:
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:

NEW Rx Submit .:. Manual Entry

Patient Info

Compounded Medication Info

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