Prescription Request - Gruene Road Pharmacy

Compounded Medication Prescription Request

Patient Name

First

Last

Date of Birth

mm/dd/yyyy

Medication

Dosage Form

Strength

Prescriber Phone

Prescriber Name

Practice / Clinic Name

Prescriber Phone

Prescriber Fax

Prescriber City (Optional)

I authorize Gruene Road Pharmacy to contact my prescriber regarding this prescription request
I understand that submitting this request does not constitute a prescription and does not guarantee that a prescription will be issued and medication dispensed. Gruene Road Pharmacy must receive a valid prescription from an authorized prescriber before dispensing prescription medication.