Online Order Submission

Online Order Submission

Our simple 3-step process takes less than 5 minutes if you have the corresponding clinical documentation available. A confirmation of your order will be sent to the email address provided.
Select a Medication*

Step 2 of 3: Treatment Documentation

Please provide additional instructions and relevant clinical documentation.
Prerequisites to Treatment
Click here and select the desired medication to see the supporting clinical documentation required to submit this order. Incomplete documentation will delay the treatment process.
Attach prerequisites to treatment:

Cancelof
I verify that I have uploaded the following information

Labs and tests supporting diagnosisOffice/progress notesDemographics

Step 3 of 3: Context Information

Please provide information about the patient and referring provider and let us know how to contact you.
Patient Demographics
Patient Name*

First NameLast Name
Address
Date of Birth*

MonthDayYear
Date
Mobile Number*
Please enter a valid phone number.
Allergies
If none, leave blank.
Weight (kgs)
Therapy Type*

New Start TherapyContinuation of Therapy
Referring Provider
Provider Name*

First NameLast Name
Ordering Physician NPI*
NPI
Practice Name & Location
Leave blank if none
Provider Signature*

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Office Contact Information
Office Contact Name*

First NameLast Name
Job Function*

MD/DONP/PAMedical AssistantRN/LPNPractice Administrator/ManagerReferral/Prior Auth CoordinatorOther
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Work Email
example@example.com

Step 1 of 3: Order Information