Patient's First Name * Patient's Last Name * Patient Date of Birth *

Requester's First Name * Requester's Last Name * Phone Number * Email *

Pharmacy *

Retail Mail order

Name of Pharmacy * Address of pharmacy *

Is this a pharmacy change? *

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Choose shipping method *

Standard ($39.85 USD) Expedited ($56.17 USD)

I need to speak to Dr. Hossalla *

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