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Our expertise enables
    us to compound
    medicines in a variety
    of forms to meet the
    needs of each patient.

State-Of-The-Art
    Pharmacy with over
    11,000 compounds
    in our database.

Prescriptions tailored
    to meet the
    individual's needs.

We accept most
    Prescription insurance
    plans.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Leiter's Online Prescription / Order

To fill your prescription(s) / forms online, please complete the Request form below.
This form is not to Refill a prescription. To refill please go to refill online section.

Please note that this is a Secure Processing Web Page

* INDICATES REQUIRED FIELD

Patient's Information:
* First Name:       *Last Name:    
(Exactly as appears on the prescription)
Facility Name :      
* Address:             Date of Birth:  
* City, State, Zip: * Phone:          

Doctor's Information: Billing Information:
* First Name: Card Type:
* Last Name: Card No.:
* Address: Verification No.:
* City, State, Zip: Expiration Date :
* Phone: email:

Prescribed Medications:
Medication #1: Strength:  
Quantity:         Directions:
Number of refills :         
Medication #2: Strength:  
Quantity:         Directions:
Number of refills :         
Medication #3: Strength:  
Quantity:         Directions:
Number of refills :         
Medication #4: Strength:  
Quantity:         Directions:
Number of refills :         
Medication #5: Strength:  
Quantity:         Directions:
Number of refills :         
Comments:
                 

* Would you like to:
Prescription will be picked up from pharmacy
Prescription to be mailed to your office by Priority Mail
Prescription to be mailed to your office by FedEx
Prescription to be mailed to your patient's address