This form can be used to request a prescription from one of our pharmacy partners.

Please note:

  • Your doctor must have already issued your prescription and sent it to a pharmacy
  • By submitting this form you are providing us with all the information we need to transfer your prescription to one of our pharmacy partners so they can fill and deliver it
  • Refer to our home page for partner hours of operation - any orders placed after hours will automatically go out the next day