Prescriptions Request / Transfer

Can't come to us?  Don't worry, we'll ship to you!

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 *
0 of 350
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) *
Drag and drop files here
Physician Information
Physician Name *
Physician Fax Number *
Physician Phone Number *
Additional Comments *
0 of 350
Authorization *
Terms *