Use our convenient online form to securely submit your prescription and insurance information. Follow the simple steps below to ensure we have all the details needed to serve you efficiently.

How It Works:

Fill out the required fields, including:

Personal Information: First Name, Last Name, Date of Birth,

Address, Phone Number, Gender.

Emergency Contact: Name and Phone Number.

Health Details: Height and Weight.

Doctor's Information: Name, Address, and Phone Number.

Upload clear photos of:

The front and back of your insurance card.

Your prescription.

Once you've completed the form, simply hit Submit Prescription,

and your information will be securely sent for processing.