Nursing/Group homes with whom we have done business in the past may order on the Internet by using this page to order. In order to use this form, you must follow the following instructions:
We must already be doing business with you, and you must have prior approval by one of the pharmacists to use this type of order form.
We must already have a prescription for the patient from the physician on file in our office.
The previous prescription must already have refills ordered on it.
The refill order must not have expired.
When you are finished ordering for a particular patient, or have filled up the order sheet, push the "submit" button at the bottom of this page. If more medications are being ordered than there is room for, start again on a new form.
Items marked with a RED * MUST be filled out
| Patient Last, First Name * | Ordering MD Name * | Rx Number | Medication Name* |
Dosage * change ? | State New Sig. |
| 1. | Yes No | ||||
| 2. | Yes No | ||||
| 3. | Yes No | ||||
| 4. | Yes No | ||||
| 5. | Yes No |
Comments regarding this order:
This order is prepared by *: Degree*
Date *:
If you are sure that you have filled out everything correctly, click on the "Submit" button. If you need to 'blank out all of the boxes, push the "Reset" button.
It is best, however to go to the top of this page, and check everything to make sure it is correct so that you do not have to do anything over again. When checking make sure there are no "required" spaces showing. If there are, you will need to fill them out, or else the form will not "submit."
Thank you for filling out this form and using the Internet. As you can see this is a very simple way of ordering your medications. They can be ordered anytime of day or night; you can expect us to call you back the next business day.
