Prescription Request

For existing patients, prescriptions may be requested by email by completing this form or by Facebook message (not phone). 24-hour notice is required for all requests.

If you have not been seen in over a year, a one-month supply will be requested with no refills IF an appointment is scheduled. Appointment scheduling is also made by email or by Facebook message (not phone).


"*" indicates required fields

Date of Birth*
Brand or Generic?*
Address of Pharmacy*
This field is for validation purposes and should be left unchanged.