medication request form


Most of our patients report that they begin feeling dramatically better in just 14 days!  Don’t wait to get started, fill out the form below and one of our clinical pharmacists will review your information and contact you.

We will then contact your doctor on your behalf with our recommendations for a prescription for the best custom compounded medication. We will also check to see if it’s covered by your insurance plan.

Once a prescription is approved by your doctor we will work with you to make a custom-compounded medication. You can either pick it up or we would be happy to mail it directly to you. Just let us know which you prefer.

Name *
Birthday *
Phone *
Please share a description of your symptoms so we can determine what medication would best get you back to your best.
On a scale of 1 to 10, what has been your average pain level in the past 7 days?
On a scale of 1 to 10, what has been your worst pain level in the past 7 days?
Pain Symptoms
Please check any boxes below that describe your pain
Name of Doctor
Name of Doctor
Doctor's Phone Number
Doctor's Phone Number
Doctor's Fax Number
Doctor's Fax Number