Prescriptions Request / Transfer

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How It Works

In order to provide you with the best care possible, please provide us with the following information. We will contact your doctor first, to obtain the prescription information. Then we will process your prescription through your insurance. Finally, we will contact you to notify you of the status of your prescription and how much your co-pay will be.

Note: We are not an open door pharmacy. We only accept Rx’s via fax or phone directly from your physician.

Ask A Question

Full Name *

Date of Birth *

Address *

Phone *

Email *

Message *

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Insurance Information

Insurance Provider Name *

Insurance PCN *

Are You The Primary Insurance Holder? *

Insurance Bin # *

Insurance Member ID *

Insurance Pharmacy Phone # *

Insurance Card (Front Side and Back Side) *

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Select files

Physician Information

Physician Name *

Physician Fax Number *

Physician Phone Number *

Additional Comments *

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Authorization *

I authorize Avni Apothecary to use the above information to process my prescription, once received from my physician.

HIPPA *

I have read and understand AVNI Apothecary's HIPPA Policy.

Terms *

I agree to the Terms Of Use

SUBMIT