Order Forms

Please download one of the following forms to order by fax. You may complete it and fax it directly to the number on the form. Our pharmacy will process your order within 72 hours, and send to you via the shipping method chosen.

Compounded formulations typically prescribed in the following categories:

Ophthalmic Patient Specific Order Forms

• Epinastine-Brimonidine Order Form
• Injectable Order Form
• LessDrops^® Fax Order Form
• LessDrops Electronic Order Form
• Lessdrops Mydriatic Kit Order Form
• Mydriatic 2,3,&4, Atropine Fax Order Form
• Mydriatic 2,3&4, Atropine Electronic Order Form
• Mydriagel Order Form
• IV Free^® Order Form
• Simple Drops^® Fax Order Form
• Simple Drops Electronic Order Form
• Total Tears^® Fax Order Form
• Total Tears Electronic Order Form

Integrative/Other Order Forms

• Integrative Injectable Fax Order Form
• Integrative Injectable Electronic Order Form
• Oral Order Form

Please note: If faxed, the prescription must be sent in by a prescribing practitioner to be considered.