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

First Name

Last Name

Email Address

Birthday

YYYY

Phone

(###)

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Known Allergies

Current Medications

Current Symptoms

Please share a description of your symptoms so we can determine what medication would best get you back to your best.

Average Pain Level

On a scale of 1 to 10, what has been your average pain level in the past 7 days?

Worst Pain Level

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

Constant Ache

Burning

Sharp/Shooting

Stinging/Tingling

Numbness

Name of Doctor

First Name

Last Name

Doctor's Phone Number

(###)

###

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Doctor's Email Address

Doctor's Fax Number

(###)

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