Prescription Request

Your Name *

First Name

Last Name

Phone *

(###)

###

####

Prescribing/Primary Doctor *

Dr. Charlie Read Kydd

Dr. Shawn Day

How would you like to receive your medication? *

*Controlled drugs cannot be shipped and must be picked up in person

I will pick it up after 24 hours

Please ship to me (additional $13.50)

IMPORTANT: *

Please allow a minimum of 24 hours to process your request, Monday thru Friday. If submitting your request on Saturday or Sunday, the earliest you may pick up is Tuesday morning. **PLEASE NOTE: You will not receive notification from our office when your medication is ready for pick up. If shipping option is selected, your medication will be shipped after 24 hours. By law, we are not permitted to ship controlled/monitored drugs; these must be picked up.

I understand