• Sterile Prescription Order Form

    Please note: *AN ACCEPTED FORM OF ID IS NECESSARY TO PROCESS TESTOSTERONE ORDERS*
  • IMPORTANT: Compounded formulations are not available “For Office Use”. - Compounded prescription orders must be patient-specific. - To avoid delays in processing, you must complete the patient information section for each compounded prescription
  • Patient Information:

    Please fill in all fields to avoid delay in processing:
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  • Prescription:

  • Drug # 1*
    Qty:
    Refills:*
    Directions:*
    Purpose:*

  • Drug # 2
    Qty:
    Refills:
    Directions:
    Purpose:

  • Drug # 3
    Qty:
    Refills:
    Directions:
    Purpose:

  • ***Please note: Georgia Requires Prior Patient Authorization to
    Ship Prescriptions to Practitioners.

  • Clear
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  • Shipping and Billing information:

  • Credit Card on file:

    ***Please note that when using a credit card on file, it is necessary to provide us with the last 4 digits & the expiration date of that card EVERY time an order is placed***
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  •  3505 Austin Bluffs Pkwy., Ste. 101
    Colorado Springs, Colorado 80918

    www.collegepharmacy.com

    Tel: 800-888-9358 / 719-262-0022
    Fax: 800-556-5893 / 719-262-0035
    e-Fax: 866-480-7483

    STORE HOURS

    Mon - Fri: 8:30am - 6:00pm
    Sat & Sun: On Call

    newpatient@collegepharmacy.com

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