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.

To submit your order electronically, click here to register for our MaxRx Prescriber Portal™

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 Mydriatic Kit Order Form
• Mydriatic 2,3,&4, Atropine Fax Order Form
• Mydriagel Order Form
• IV Free^® Order Form
• Simple Drops^® Fax Order Form
• Total Tears^® Fax Order Form

Integrative/Other Order Forms

• Integrative Injectable Fax Order Form
• Capsule Order Form

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