Rx Submit (NEW) Manual Entry
PLEASE NOTE: WE DO NOT FILL PRESCRIPTIONS WRITTEN BY THE PROVIDER, FOR THE PROVIDER. While 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 Name
Last Name
Provider DEA or NPI#
*
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
Person Submitting Name & Role in Practice
*
First Name
Role
Provider Phone #
*
Provider Fax #
*
Provider Email Address
*
example@example.com
Patient Info
Patient Name
*
First Name
Last Name
Species
Please Select
Human
Feline
Canine
Other
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
Date
Patient Phone #
*
Please enter a valid phone number.
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
Medication Info
Medication Name
*
Medication Strength
*
Medication Form
*
Please Select
Capsule
Cream
Liquid
Sublingual
Suppository
Injection
Eyedrop
Other
Medication Instructions
*
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
Continue
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