Prescription Form

Your name here.
phone number to reach prescriber during business hours
Enter your email here. If you would like a copy of this sent to a different email address than your default, please enter it here.
Name of the person to receive the remedy .
What is the patient's email address? Put it here.
Please use full Latin Name without abbreviations for clarity: e.g. Arnica Montana, Belladonna, Clacarea Carbonica, etc.
Enter Numeric Value of Potency, e.g. 30, 200, etc.
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.