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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.
 Canada
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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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Phone
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Fax
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Physician Information: (Please Print Clearly)
– Section C
First Name
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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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Str
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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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2.
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3.
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4.
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5.
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6.
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7.
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8.
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9.
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10.
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11.
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12.
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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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