Prescription Upload
For paper prescriptions only. Not needed for prescriptions submitted electronically or Telehealth prescriptions
Name
*
First Name
Last Name
Email of Best Contact
*
example@example.com
Upload Prescription
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name of Prescribing Doctor
*
Ship Address (If not on prescription)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: