Prescription Form

Contact 1
If you would like a copy of your prescription sent to a different email address than yours, please enter it here.
Select Potency Scale, e.g. C, X, LM, etc.
0 = No refills, patient must contact prescriber for a new prescription. 1 = 1 refill of current potency, no new prescription required, etc. Refills are for current potency only, change of potency requires a new prescription.
e.g. single dose, half dram, 2 dram, 1 oz, 4 oz, etc.
Example: Take as directed by your homeopath.
Example: Thank you, have a wonderful day.