Your information has
been sent directly to our online Pharmacy. The final step is to print this
page, fill out the information below, and have your physician fax it along with your new prescription to us with this cover
page to complete your order.
* NOTE * Due to the high volume of orders we receive. Please give us 72 hours before you try and call us to confirm receipt of your faxed prescriptions.
Fax to: null
Web Order Reference Id:
Total Number of Pages (including this sheet)
Your Name: (as written on prescription)
Address:
Phone Number:
BirthDate: (YYYY/MM/DD)
Number of Prescriptions in this Order:
Please Attach Prescription to the Box Below Before Faxing:
Attach Here!
* * * IMPORTANT * * *
Law requires that the full patient name, address (and telephone number) must be CLEARLY PRINTED on the written prescription in order for this prescription to be filled.