Prescriber Form

Prescriber Form

Please provide your doctors information. Make sure you only list the doctor who prescribed the medication you are seeking.
Your Name*

First NameLast Name
Your Date of Birth*

MonthDayYear
Date
Provide the Name of Doctor Prescribing the Medication your seeking*

First NameLast Name
Mailing Address of your Doctor's Office*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor's Office Number*
Please enter a valid phone number.
Doctor's Fax Number
Please enter a valid phone number.
Copy of your Prescription

If you have a copy of your prescription, please take a photo of it and upload it here
File Upload

Cancelof
If you do not have your prescription, please provide the following information:
Name of the Medication
Dosage Information
MG or MCG Example: 20mg
How much do you take?
Example: 1 pill twice a day, or 2 pills once a day.
Patient's Phone Number
Please enter a valid phone number.
Patient's Email
example@example.com
Important: After you submit this form please return to our website at communityrx.com and complete the other required forms. Thank You.
Please verify that you are human*
Should be Empty:

Copy of your Prescription