Prescriptions will be telephoned to the pharmacy listed below within two working days of your request. Written prescriptions for control substances will be ready within two working days of your request at the office you have specified below.

 

Your Name* :

Your E-mail Address* :

Your Phone Number* :

Child’s Name* :

(First, Middle, Last)

Birthdate* :

Child’s Social Security Number :

Insurance Name* :

Insurance Number* :

Medicine requested (name from the medicine bottle)* :

Strength of medicine (in mg)* : 

How does your child take it (once daily, every 6 hours, etc)* :

Pharmacy phone number for us to call:

Comments* :