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Choose your dispensing pharmacy:
Choose the country or countries below that you will allow us to dispense your medication from. All of the pharmacies are licensed in the practice of pharmacy in the country they operate. Based on your decision our website will choose where to send your prescriptions based on product availability and/or price.
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United States |
Britain |
New Zealand |
Australia |
Israel |
All |
Patient Information: (Please Print Clearly) – Section B
First Name
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Last Name
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Address
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City
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State
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Zip
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Fax
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Physician Information: (Please Print Clearly) – Section C
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State
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Last Name
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Zip
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Street 1
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Phone
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City
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Fax
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DEA#
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License #
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Prescriptions – Section D
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Medications (Please Print Clearly)
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Qty
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Sig
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Generic Allowed?
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# refills
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***Please note that we will only send a maximum of 3 months supply per medication order. Refills are allowed.***
***We can only allow refills for up to 1 year for each medication***
***We will substitute generic brands unless brand name drug is specified or a generic is not available***
*** Physicians please attach prescriptions or complete Section D
Physician Signature_________________________________ Date__________________________
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