Order Forms

For maximum processing efficiency please contact us today to set up your account for placing orders on the MaxRx Prescriber Portal.

All orders submitted to our pharmacy through the MaxRx Prescriber Portal will be promptly processed and sent to you via the shipping method chosen.

To order by fax, please download one of the following forms. You may complete it and fax it directly to the number on the form and 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:

503B Bulk Order Form

• 503B Order Form

Ophthalmic Patient Specific Order Forms

• GoDropless^®Order Form
• LessDrops^® Topical Order Form
• Other Topical Order Form
• IV Free^® Order Form
• Simple Drops™ Order Form
• Total Tears™ Order Form
• Custom Compound Order Form

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