New Prescriptions

Use the form below to establish your prescriptions with us. If you prefer to give us this information over the phone, please call us locally at 234-1973 or toll-free at 1-800-251-7971 .

Please provide the following contact information:

First name

Last name

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Work Phone

Home Phone

FAX

E-mail

Your Date of Birth

Enter your physician's name, location and phone number (including area code) in the space provided below.

Indicate whether you will pick up your prescription or if you want us to mail it.

Please provide the following ordering information:

QTY Drug, Strength and Directions

BILLING

Credit card

Cardholder name

Card number

Expiration date