Patient Information

Registration here will save us time. That helps you save money.

To serve you, our consultant pharmacist needs a detailed medical history. For your convenience we have provided this online form. Simply complete the form as it applies to your current condition and press the "Press to Submit" button at the bottom. You need only fill in the information that is appropriate to you and leave other fields blank.

If you prefer, simply print this form, fill in the data manually and FAX (866) 651-8929 or mail it to us via traditional mail.

If you have any questiuons, please call us the Pharmacist you selected or call: (239) 410-4323

Please Choose a Pharmacist

Please choose from the list below to serve you, if you would like to see a list of all our participating pharmacists, click here.