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

• Injectable Order Form
• LessDrops^® Topical Order Form
• Mydriatic 3&4, Atropine Order Form
• IV Free^® Order Form
• Simple Drops^® Order Form
• Total Tears^®Order Form

Integrative/Other Order Forms

• Integrative Injectable Order Form
• Oral Order Form

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