Order Your Script
(New Patients)

Please select an option *

Human

Animal

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Is this a new medication or has it been used before?

New

Used Before

Gender *

Male

Female

Prefer not to say

Are you pregnant or breast feeding?

Pregnant

Breastfeeding

N/A

Collection *

Pick up

Delivery (additional fees apply)

Keep repeat on file at pharmacy?

Yes please

No thanks