Prescription Request

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

If you have not been seen in over a year, please make an appointment with Kelly before a prescription is filled. A one-month supply will be ordered (without refills) if an appointment is scheduled. Appointment scheduling is done via 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.