Tirosint Direct Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Month
Day
Year
3
E-mail* This field is required.You will receive an email with more information after completing the form submission.
4
Contact Number:* This field is required.
Area Code
Phone Number
5
Shipping Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Taking any medications, currently?* This field is required.
Yes
No
7
Please List Current Medications* This field is required.Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
8
Are you Allergic to any Medications?* This field is required.
Yes
No
9
Please List Allergies here* This field is required.Please list all Allergies. If more than one, separate them with a comma.
Huge
Large
Normal
Small
Ok
Ok
10
How will we Receive your Prescription?* This field is required.
I am Mailing my Prescription
My Doctor is Sending my Prescription
I do not currently have a prescription, I am interested in learning more about Tirosint
11
Please Mail Your Prescription to

Highland Specialty Pharmacy

23 Town Center Square

Hattiesburg, MS 39402

Highland Specialty Pharmacy will contact you once your prescription has been received. Please allow three business days for Highland Specialty Pharmacy to receive your prescription.

If you have not been contacted within five business days, please contact the pharmacy. Highland Specialty Pharmacy contact information will be provided in your submission email.
12
Please Have your Doctor Send your prescription to

Fax: 601-268-6690

or

E-Scribe: 2588842

Have your Doctor Call: 601-268-6033

Highland Specialty Pharmacy contact information will be provided in your submission email.
13
Where did you hear about Tirosint?* This field is required.
Family Member
Online
Friend
Doctor
Prefer not to answer
14
Thank you for your Interest in Tirosint Direct!

You will receive an email with more information. For further questions, please give us a call using the contact information provided.

We look forward to Offering you savings on your Tirosint Prescription.

Please continue to submit
15
Auto Refill?* This field is required.Auto Refill may be turned off at anytime.
YESNO
16
Auto Refill Terms* This field is required.Auto Refill may be turned off at anytime UPON REQUEST. Once your prescription has been shipped, your medication cannot be returned. Any changes to shipping address or prescription strength MUST be communicated to the pharmacy BEFORE shipment.
I Agree to Auto Refill Terms
I do NOT Agree to Auto Refill Terms
17
How is your experience using Tirosint Direct?
18
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