Patient Information
First Name
Last Name
Email
Daytime Phone
Evening Phone
Shipping / Delivery options:
Free citywide delivery in San Diego & Imperial counties
Please indicate the type of transaction:
New prescription
 
Physician Name
Office Phone
Refill
Transfer presciption from another pharmacy
 
Name of pharmacy
Phone
Medication name(s) or numbers:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Additional Information
Address
City
State
Zip
Sex Male
  Female
Are you allergic to any medications:
  No
  Yes, please list the medication(s) below:
 
If we need to contact you, what is the best way:
 
  Evening Phone
  Email
  Mail
Insurance information
Company
ID#
Group #
Phone
If this is a new prescription, how will you be sending it to us?
  the original prescription to us at
120 University Ave, San Diego, CA 92103
  the prescripton to us at 619-260-1031
  can call the prescription in at
619-260-1010 or 866-260-1387
  your doctor to get the prescription (make sure phone is listed above)