Prescriber Compound Request

Fill out the following form to request a prescriber quote from our Compounding lab

Compound Name/ Active Ingredients*
Strength*
Form
Species
Day's Supply
Prescriber Information
THIS MEDICATION REQUIRES A PRESCRIPTION*
To fulfill your order, we will require a prescription from you or your Prescriber. We will only compound and dispense upon receipt of a valid patient specific prescription. After making a selection, please provide the relevant information below. If you do not yet have a prescriber, leave the fields blank: we're happy to make a referral.
Prescriber's Name
First Last
Office number (and extension)
The fax number for the Pharmacy is: (813) 254- 8396. should you choose to fax over your request.
Other Pharmacy Name & Number
If requesting Rx Transfer
Contact Information
Name*
First Last
Contact Email*
Cell Phone*
Home Phone
Notification & Delivery Preferences
How would you prefer to be notified?*
- Select All
- Text
- Phone
- Email
Delivery Options
Notes for Pharmacy, Shipping Address, Alternative Ingredients, etc.
- Opt me out of receiving pharmacy communications
- Subscribe to monthly newsletter
Comments
This field is for validation purposes and should be left unchanged.