Prescription requests are retrieved from this site several times daily. If you have an urgent request on a weekend, you should contact us by phone. There is no need to submit multiple requests for the same prescription.

Please fill in all information as completely as possible. Then click the SUBMIT button at the bottom of the page.

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1 Step 1
First Name
Last Name
Middle Initial
Date of Birth
Phone Number
ReferrerReferrer
Drug Name
Dosage (mg)
Quantity
Pharmacy
Pharmacy Phone
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Office Hours

  • Monday - Thursday 7:30AM - 9:00PM
  • Friday 7:30AM - 4:00PM
  • Saturday 8:00AM - Noon