If you prefer, you can download this form (PDF), print it out, and fill it out by hand.
To submit this form, please enter your contact information and at least one referral or primary doctor below. If you have more than one doctor that you want to be informed, enter the additional doctor information where it says ￼￼￼“Referring or Primary Physician #2 (optional)”. If you have a pharmacy that needs to be informed, enter their contact information at the bottom of ￼￼￼￼this form. Once the information has been filled out successfully, you will get an email receipt and our physicians will review it.