Physician Order Form

Step 1: Fill out your prescription information below.

1. Fill out all fields in the Patient Information and Physician Information sections of the following form. This can be done electronically by clicking each box and typing the required information.
2. Click the Submit button and a new PDF file will be generated. Simply send the form to us and we'll contact your Physician!

Alternatively, you may also fill out this form and fax it to your Physician yourself. If you chose to do so, follow the same instructions as above to fill out the form. Once completed, press the Print Form button and fax the printed copy to your Physician's Office Fax Number.

Please call 1-866-414-9700 if you require assistance completing this form.