Sterile Prescription Order Form

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:
Todays Date: *

Month Day Year
Date
Date Needed by: *

Month Day Year
Date
Name *

First Name Middle Name Last Name
Sex assigned at birth: *

Male Female
Date of Birth *

Month Day Year
Date
Patient Street Address (No P.O. Boxes) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
PURPOSE (Required for Testosterone) (Anabolic Steroids): *

HRT Menopausal Symptoms Hypogonadism
Allergies: *

NKA
GOV’T ISSUED ID REQUIRED TO PROCESS TESTOSTERONE ORDERS: *
(Drivers License, State Issued ID, Passport or Military ID)
Prescription:
Drug # 1blanks*
Qty:blank
Refills:*
Directions:*
Purpose:*
Drug # 2blanks
Qty:blank
Refills:blank
Directions:blank
Purpose:blank
Drug # 3blanks
Qty:blank
Refills:blank
Directions:blank
Purpose:blank
***Please note: Georgia Requires Prior Patient Authorization to
Ship Prescriptions to Practitioners.
PRACTITIONER INFORMATION: (please choose one) *

MD MB DO PA NP ND DDS DVM DPM
Practitioner Name (Please Print) *
Signature *

Clear
DEA # *
License # *
Office Address (No P.O. Boxes) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Fax Number *

Area Code Phone Number
Contact/Faxed by: *
please provide name
Shipping and Billing information:
Shipping Information: *
Please choose one.
Billing Information: *
Please choose one.
Type of Credit Card: *
Please choose one.
Name on Card *
Billing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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***
If your Credit Card is already on file with us please provide the last 4 #s of the card on file *
Please provide the expiration date of the card on file with us *

Month Day Year
Date
I understand that For liability purposes, FedEx will require an adult signature upon delivery. This can be waived if a signature release form is signed and sent back to us. *
(Initial)
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
Should be Empty:

Sterile Prescription Order Form

Patient Information:

Prescription:

Shipping and Billing information:

Credit Card on file: